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.,.z <br />i~ <br />• STATE Ur CC'LOR~DV • III' ! IIIIIIII <br />ivII~ED L:~tiD RECLA~IATIO~`i BO.aRD <br />P:~RTY STATUS REQUEST FORM <br />_ [request that I be named as a pam~ <br />I request chat I rot be Waned as a parry <br />~ I request to be withdrawn from party status <br />In the matter of File No. M-~- `j~j¢: <br />S'l~nar ~arddv~ <br />Printed N e <br />58 4 0 1~r 1 lS <br />A~dres~ ~ C~ n 12~~ <br />City, State Zip Code <br />c /~~'11~tQ[.f <br />Sienature T <br />~119~3~2- 319 _ <br />Home Phone <br />c?l9 ~ 2?h _ 7}60 <br />ti~tork Phonc R <br />FAX ~ <br />U <br />Date <br />If you are requesting to be named as a party, please briefly describe below how you may 6e <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 Ivlined Land Reclamation Board. .. <br />