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S~'ATE OF COLORADO <br />MIl~'ED LAND x2ECLAMA.TIO~ BOARD <br />PARTY Sx'ATL1S WIT~RAW FORM <br />In the matter of File No. M- -_ <br />Name of Operator/Applicant and Site: <br />PermitJPermit Amendment Application. <br />I request I be withdrawn from patty status <br />T request T be withdrawn from party status and I wish to address the $oazd at the formal hearing, if <br />held, as a non-party <br />(Please note that iP all objecting parties withdraw rior to We date set far the Board's consideration of the <br />application, the application maybe appror ed by the Office and no $oard hearing held. Thus, there will not be <br />an opportunity for any person to address the Board on any issues related to the application, Also, t}te Board is <br />not obligated to consider apy issues raised by a party Utat has withdrawn.) <br />Regazdless of a party status, the Division thoughtfully considers each issue submitted in writing to the Division and <br />provides a response to those issues in the bivision's "Rationale for Rcconmtcndation ". The "Rationale" is available to <br />any person by contacting the Division. For persons who do not wish to became a party or withdraw as a party in This <br />matter, please contact the Division for infortna6on on application status. <br />(Please provide the following informstion if you have or wish to have party status, thank yau.) <br />Printed Name <br />Address <br />City, State <br />Ii-Mail Address <br />Signature <br />Phony # <br />~~ <br />Walk Phone # <br />Tap Code FAX # <br />bate <br />25V-d 800!600 d 252-1 901820800[1+ rtso~aeg 9 s~eieuiyy }o uoisini0 opeiolcJ-Vi08d !2 5l 5002-30-20 <br />