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STATE OF COLORADO . <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS REQUEST FORM <br />I request that I be named as a party ~~~~ <br />I request that I not be named as a party ~~G X11999 eo~0~~ <br />_/ G <br />~J~` I request to be((~ ithdrawn from party status ~o~o~~\~e<a~t' <br />In the matter of File No. M-C~- <br />For people who do not wish to become parties in this matter, information on the permit <br />application process can be requested from the Division of Minerals and Geology. <br />_I~VIe I I Ste. { e r Ir,e~ <br />P 'nted ~IamX / I~~ <br />n ~/~, `i <br />o ~~o~ <br />City, State Zip Code <br />~~l ~~- 837 <br />H,pm P~~n # <br />- ~?~3 <br />Work Phone # <br />FAX # <br />Date <br />It you are requesting to be named as a party, please briefly describe below how you may be <br />affected or aggrieved by agency action in the matter referenced above. Include a statement of <br />your opposition or support in the matter. You may attach a written statement to dtQs form instead <br />of filling in the space below. Include a specific description of the issues that you feel need to be <br />addressed at the final hearing before the Mined Land Reclamation Board. <br />1 <br />i <br />