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<br /> <br />STATE OF COLORADO <br />MINED LAND RECLAMATION EUARD <br />PARTY STATUS REQUEST FORM <br />In the matter of File No. M-_- , Permit/Permit Amendment Application. <br />Name ofOperator/Applicant and Site: <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I request to be withdrawn from party status 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 />I understand that if I am not a party, my statements of concern or objection to this <br />application will not be considered during the review of the application, but I may address <br />the Board on this matter at the final hearing, and may present my concerns as an <br />interested member of the public. <br />For people who do not wish to become parties in this matter, information on permit <br />application status can be requested from the Division of Minerals and Geology. <br />Printed Name <br />Address <br />Home Phone ~ <br />s ~ - <br />Work Phone ~ <br />City, State Zip Code FAX R <br />E-Mail Address <br />Signature <br />Date <br />If you are requesting to be named as a party, please briefly describe below: <br />1. how you may be affected or ag;rieved by the Board's decision in the matter referenced above, <br />2. your opposition to the matter, including a specific description of the issues that you feel need <br />to be addressed at the final hearing. (You may attach a written statement to this form instead <br />of using the space below.) <br />