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STAT III IIIIIIIIIIIIIIII ~ <br />~ ~ ~NED LANL ~.r...r,r;~.~ti~~.~1V-BOARD R@q~• <br />N~ <br />PARTY STATUS REQUEST FORM AUG Z 3 ~yy9 <br />_ I request that I be named as a party ~° M ~~~ $ Gep <br />_ I request that I not be named as a party ~E/~ ~ <br />V <br />I request to be withdrawn from party status ~~UgL~C F~ ~~~~CP <br />In the matter of File No. M-~,.-~: ~/T~'/~ ~~' d~ O~~ <br />Cop~i~n ~^~~~ ~i ~- ACT <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 />Prime Name Home Phone # <br />o~ ~ ( 1 _ <br />Addre ~~ ~ Work Phone # <br />` ( ) <br />City, State Zip Code FAX # <br />E-Mail Addres <br />~, ` <br />Sig a Dale <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 />your opposition or support in the matter. You may attach a written statement to this 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 Boazd. <br />