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Q~~~~~ S~P~~ -~-~~~~ ~~ n~~~ ~~SS~~~~~~w - III IIIIIIIIIIIIIIII <br />ST~.TE OF COLGFcAUv RECEIVED <br />MINED LAND RECLA~I4TIOV BOARD <br />PARTY STATUS REQUEST FORM MAY 17 1999 <br />Division of Minerals 8 Geology <br />_ I request that I be named as a parry <br />~\ / I request that I not be named as a party <br />~c I request to be withdrawn from party status <br />[n the mattes of File No. M-~-~~: <br />~hr::. I,Jo,(Ah~ <br />Printed Name ~~ ,~~ - <br />d-~I S(1 ~ a~rP <br />Address <br />G ~s . C o . ~ D ~ a. ~-~ <br />Ciry, rate Zip Code <br />n cw V L J t' 1~ ~t h~ <br />Signature <br />c~rg, s~_9~ ~s 79 _ <br />Home Phone <br />'b'oth?hr;nc <br />FAX ~ <br />~ 99 <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 />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 />