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Fin-`~~~11 719,269,8595 <br />Ju~03;99 09:31a Dway~ ~{~~I~~~~~~{111111 • <br />ST:1Tx`.:7F CC~:.OItaDO <br />itifItiED LA`iD RECLAIM-~T1O:`~ EO:~RD <br />PARTY STATUS REQUEST FORti! <br />_ I request that I be named as s party <br />I request that I riot be named as a ezry . <br />I request to be w~th raven from parry status <br />In the matter of File No. i1~1- t' ,-ml~: <br />p.2 <br />Printed Nair. <br />f,~ddress <br />C ry, Stat- a -~ ~ Zip Code <br />Signature-r <br />Home Phone R <br />(7i r lays - ~'7lO <br />~;'orJ:?hoot R <br />r ~ <br />FAX ar <br />~t~ 3FS~i <br />Daze <br />If you are requestia; to be named as a party, please briefly describe below how you maybe <br />affected or aga eved 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 tha[ you feel need to be <br />addressed at the final hearing before the Mined Land Reclamation Board. .. <br />