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STATE OF COLORADO <br /> r 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: <br /> I request I be withdrawn from party status <br /> I request I be withdrawn from party status and I wish to address the Board at the formal hearing, if <br /> held, as a non-party <br /> (Please note that if all objecting parties withdraw prior to the date set for the Board's consideration of the <br /> application,the application may be approved by the Office and no Board 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,the Board is <br /> not obligated to consider any issues raised by a party that has withdrawn.) <br /> Regardless 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 Division's "Rationale for Recommendation ". The "Rationale" is available to <br /> any person by contacting the Division. For persons who do not wish to become a party or withdraw as a party in this <br /> matter, please contact the Division for information on application status. <br /> (Please provide the following information if you have or wish to have party status,thank you.) <br /> Printed Name Home Phone# <br /> Address Work Phone# <br /> City, State Zip Code FAX# <br /> E-Mail Address Date <br /> Signature <br />