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STATE OF COLORADO :~'~~' = ~"~~~~~'~° <br />MINED LAND RECLAMATION BOARD P~A~ '1 0 L~J5 <br />TATU ~WIT_IIDRAW FORM -~.;;;~,~}:~...~,.,_ „~~,~3~:~;e <br />In the matt of File No. M-~- ~~ -I Permit/Permit ndment Application. <br />Name of Operator ltcan r (~ i,LC~iT, /tiY.r n iv<~t i3C2v_~2 /I mac.... <br />_ I request I be withdrawn from party status and I wish to address the Boazd at the formal heazing, if <br />held, as anon-party _ <br />_(Please.note,thatif_a~_objeeting_partieswithdraw_ riorio#he,datesetfortheBoard'sconciderationof-the-- <br />application, the application may be approved by the Office and no Board hearing held. Thus, there will not be <br />an opportunity for any person to address the Board on any issues related to the application. Also, the Board is <br />not obligated to consider any issues raised by a party that has withdrawn.) <br />Regardless of a party status, the Division thoughtfully considers each issue submitted in writing to the Division and <br />provides a response to those issues in the Division's "Rationale for Recommendation ". The "Rationale" is available to <br />any person by contacting the Division. For persons who do not wish to become a party or withdraw as a party in this <br />matter, please contact the Division for information on application status. <br />(Pl a provide the following information if you have or wish to have garty status, thank you.) <br />!/ ~~ `C I~G rC''K 501-} [-~- <br />Printed Name Home Phone # <br />1805 wt©n,~ iwcT- ~~rL <br />Address <br />I,O~C~i/~ Cc's ~o53fs <br />City, State 11~~ Zip Code <br />/[T 172Utu JAN e,-Pr ('' ,¢pL-Ccvwt <br />7O) h~h4-741 <br />Work Phone # <br />c 47r~) l~ h 4 -'~1D 77 <br />FAX # ' <br />.~ ~ 0 5 <br />Date <br />Signature <br />