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~~~'(~~ MIN• LAND RECLAMATION BOARD III IIIIIIIIIIIII III <br />sss <br />PARTY STATUS REQUEST FORM <br />of File No. M-awl- d23 , Permit/Pernut A~lmendment Application. `` ~~ <br />Name of OperatortApplicam and Site: ~.e.r,~.12,$~i, f'rt ~~ ~,e'~~ ~~ t-o~-t . <br />I request thaz I not be named as a parry <br />JUN 1 4 2001 <br />I request to beanthdrewn from party status Division of Minerals and Geology <br />I understand that if Y am aot a party, my statements of concern or objection to this <br />application will not 6e considered during the review of the application, but I tray address <br />the Board on this matter at the tidal hearing, and may present my concerns as an <br />interested member of the pnbGc. <br />Por people who do not wish to become parties in this matter, information on permit <br />application status can be requested from the Division of Minerals and Geology. <br />S-Io <br />~-U~'~e{~ ~(QVl ~OVS~Y'0-Ytc{_ (~7cl~e -a~e(~ <br />Printed Name Home Phone # <br />~PU 6chc ~3b8g (97o ZB~q _ a-`7 i-7 <br />Address Work Phone # <br />5~{e,~,v,, bottrt- 5~U ~ ~a s Co BoU~ 7 ~ 970 ~ fS7v _ 9G r-7 <br />City, State -7 Zip Code FAX # <br />Vah~~a 5P~'tr'IAS~-h1,C~iti <br />E-Marl Addres~-'-1 <br />~.,. ~n ~[ 3 0 / <br />Sigma re Date <br />If you are requesting to be named as a party, please briefly describe below: <br />1. how you may be affected or aggrieved by the Board's decision in the matter referenced above, <br />2. your opposition to the matter, including a specific description of the issues that you feel need <br />to be addressed at the Snal hearing. (You may attach a written statement to this form instead <br />of using the space below.) <br />12 day of <br />:,~;crii:cd ^rd sv:om Lafore rr.e this `~-f ~~rn,`I r.. ~.l <br />~:a;; <br /> <br />~~ ~.~~ <br />x I request that I be named as a party RECEIVED <br />