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<br />r1 L'"I"1IUIZ1"LATIO~f TO 12EYKLSI?~"I':1 PARTY ~eC21Ved <br />(Please Type Or Print. The Requested Information) MAY .1 7 ~ppl <br />SIGN.Y~A'CRL•5 ~IL'ST UC 1~' BLUI: INh Dura~;go Field Olfice <br />Division of ~Air,crals B GocIo9Y <br />(Ye:iOiis Vama) (Tit;) <br />/r /--r1 <~'irru]~.f rUK gcc:~J,tl7~Ai5'/cT~i~- ,~~'/'a/S~~i~iry <br />o __ C.-/-/'tl~ _____ __ ([tame of company, ass/oc:~tiott, organization, etc.) atff <br />authorized to dc(cgnte ~ ~~~~ . ,/J /~_ /ON a /~C~/>~-~.f' G ~~/S" <br />(Puson's t amc) ~--~'_1 (Cons•.~Itac;, c~c.) <br />to reproscttt _______ (_ !`~/~ (name of person, company, asociation, <br />organization, ete.) at the ['re-hearin; Conference and/or Hearing before the tifir.ed Land Reclamation <br />13orad in this matter. I2cprescn[ative's phone number __(/~ ) 1'L ~j~-d.3~`~(1 ,and address <br />E~ <br />(Strct AdJress) (City) (State) ("LIP) <br />STG~tLI) A'.Vll DATFD'I'HIS _.~ bAY Olz ~~ _. <br />. ~~~~ If corporation attest (seal) <br />AvlhonzcJ Si~nan: rc (Hurl! be signtr! in blue urk) <br />Talc ~~/ L ~~/~ <br />S 1'ATF OF <br />ss. <br />COUNTY OF _ C ~~~ ) <br />The fo-rfj°~}aoin_~inso~n:en[ w~a~s alcKnowledgcd before the i'tis J~~_day o(_.__ n __D, ~~A~,, <br />by---/ "`^"~~/~L.f~t"`~- as o(- ( ~-K.i.----~ <br />- v GC- _ <br />NOT Y PUBLIC <br />\4y COm misa:On expirs. /~' -e23 ~d~ <br />5(GVATURF:S ~[[; 5"r I3L I\ ISLUE INIi <br />K '..:y,•r inU~e L~u,~, u.i ~, m R: prcvc n, i f ~~iy Jo: <br />