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STATE OF COLORADO <br />MINED LAND RECLAMATION BOARD <br />PARTY STATUS WITHDRAW FORM <br />In the matter of File No M-??, Permit/Permit Amendment Application: <br />Name of Operator/Applicant and Site: _ G ?tP? ?YVt?I P?iCJGl,Y1i ice, <br />1 requ t I be withdrawn from party status <br />uest I be withdrawn from party status and I wish to address the Board`at the formal hearing, <br />if eld, as a non-party <br />(Please note that if all objecting -parties withdraw rip or to the date set for.the: Board's <br />consideration of the application; the application may be approved by the Office and no Board <br />hearing held. Thus, there will not be an opportunity for any person to address the Board on any <br />issues related to the application. Also, the Board is not obligated to consider any issues raised by <br />a party that has withdrawn.) <br />Regardless of a party status, the Division thoughtfully considers each issue submitted in writing tothe <br />Division and provides a response to those issues in the Division's "Rationale for Recommendation". <br />The "Rationale" is available to any person by contacting the Division. For persons who do not wish to <br />become a party or withdraw as a party in this matter, please contact the Division for information on <br />application status. <br />(Please provide the following information if you have or wish to have party status; thank you.). <br />41-) AeW <br />Printed Name Home Phone # <br />Address Work Phone # <br />a e. 906, <br />City, State Zip code FAX <br />E-Mail Address Date <br />R <br />Signature