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~ ~ STATE OF COLORADO. <br />MINED LAND RECLAMATION BOARD <br />.. -• PARTY STATUS REQUEST FORM <br />I request that I be named as a party <br />I request that I not be named as a party <br />x I request to be withdrawn from party status <br />In the matter of File No. M- 99 - 034 <br />III IIIIIIIIIIIII III <br />Cooley Reservoir and Fulton Wildlife Area, Regular 112 Application <br />For people who do not wish to become parties in this matter, information on the permit <br />application process can be requested from the Division of Minerals and Geology. <br />City of Thornton ( ) _ N/A <br />Printed Name Home Phone # <br />9500 Civic Center Drive (303) 538 _ 7210 <br />Address Work Phone # <br />Thornton, CO 80229 (303 ) 538 _ 7427 <br />City, State Zip Code FAX # <br />eela@ci.thornton.co.us <br />E-Mail Address <br /> <br />Signature Date <br />If you are requesting to be named as a party, please briefly describe below how you may be <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 Mined Land Reclamation Board. <br />