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STATE OF COLORADO . <br />MINE;D 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 <br />I request to be withdrawn from party status <br />In the matter of File No. M-~~- DSO: <br />~\~~~ <br />~,~ y `~,~~~,°~~'G~~Ay <br />~Q' r~\oe`a ~ <br />`~V <br />O <br />J~' <br />~' <br />I <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 />/~-Ana-,, ~~ ~e/ c3°~ , zoy- 9Z 5'9' <br />Printed pName Home Phone # <br />Address Work Phone # <br />ity, State .~ ~~ Zip Code FAX # <br />E-Mail Address p~ <br />Signature 1 a`~ 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 suppon in the matter. You may attach a written statement to tltls 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 />nli .I <br />