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STATE OF COLORADO `(y)Z~~~q <br />N~ED LAND RECLAMATION ~ARD <br />PARTY STATUS REQUEST FORM <br />In the matter of File No. M-~mPV ~ q • Permit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: ~ ~t1~ ~'~ <br />~~iC~.> <br />/~ I request that I be named as a party v~y~'~04o Mti D`~~QO®l <br />I request that I not be named as a party bra/S`~Geo/p9y <br />_ I request to be withdrawn from party status <br />I understand that if I am not a party, my statements of concern or objection to this <br />application will not be considered during the review of the application, but I may address <br />the Board on this matter at the final hearing, and may present my concerns as an <br />interested member of the public. <br />For people who do not wish to became parties in this matter, information on permit <br />application status can be requested from the Division of Minerals and Geology. <br />~Yi;~vti ~. aR,~ v <br />Printed Name <br />~ ~ dge ~C 3 ~ <br />Address <br />City, State Zip Code <br />Home Phone n <br />Work Phone # <br />FAX ~ <br />E-Mail Address <br />~ignat~ ~ Date <br />If you are requesting to be named as a party, please briefly describe below: <br />1. how you maybe 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 final hearing. (You may attach a written statement to this form instead <br />of using the space below.) <br />