PERMFILE104009

• Permit No: M1999005
• IBM Index Class Name: Permit File
• Doc Date: 5/26/1999
• Doc Name: MLRB PARTY STATUS REQUEST FORM
• Media Type: D
• Archive: No

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• STATE OF COLOR_AC~ III III'lI1lI"II'I'
MIMED LAND RECLAMATION BOARD
PARTY STATUS REQUEST FORM
_ I request that I be named as a parry '~~CE~VE~
~ I request that I not be named as a parry MAY 2 6 1999
'~+~s on of Minerab & Geology
_ 1 request to be withdrawn from parry status
In the matter of File No. M-~- DO.~
Regardless of your status, please fill in your name and address so the Division can send you
information on this matter.
---G~
Printed Name
.Vi D, /90~ o3613y ~-~.~~A~L T~
A dr~ ess ~ ~ ~ ,,
City, State Zip Code
(~/9~ ,~L"~- ~ rya ~
Home Phone
Work P:::;a? #
FAX #
lylAi/ .2 7,• /lf~
DatT
If you are requesting to be named as a party, please briefly describe below how you may be
affected or aggrieved by agency action in the matter referenced above. Include a statement of
your opposition or support in the matter. You may attach a written statement to this form instead
of filling in the space below. Include a specific description of the issues that you-feel need to be
addressed at the final hearing before the Mined Land Reclamation Board.