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III IIIIIIIIIIIII III ,~D <br />~NED LAND RECLAMATION~OARD <br />PARTY STATUS REQUEST FORM <br />RECE1VEp _ I request that I be named as a party <br />~ggg ~! I request that I not be named as a party <br />~u` 2 <br />°tMlne2ri~Ge°IO9Y I request to be withdrawn from party status <br />pwis~on <br />In the matter of File No. M-~-~: <br />Received <br />JUL 1 91999 <br />Divisiorim~ Field pryer <br />of Minerals 6 Geology <br />PVB~IC F ~FF~CE <br />F~~E: M-gibE COPY <br />SITE. ~, <br />canra~rreh a.., /? ~. <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 />Pii v f n y~-~i+-rr t~_ <br />P ~nted Name <br />Address <br />~-~s?/ G y ~~~ <br />Cit ,State Zip Code <br />~ua ty,e cK ~ QGSo/ .~.~y- <br />E-Mail Address <br />Signature <br />~ y~.~~~- s~sy <br />Home Phone # <br />Work Phone # <br />~~~,,rc~-- s/S'~ <br />FAX # <br />7-/ ~-9~ <br />Date <br />If 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 />year opposition. or support in the matter. You may attach a written statement to this fore 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 />~-~t~-~ -~o X170 - ~ ~l ~ - Si o u~ 6~.~ .~( <br />