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'CE. <br />STATE OF COLORADO <br />?,`S 2011 MINED LAND RECLAMATION BOARD <br />o yield 01fice <br />purang per <br />Sa <br />O1v ety PARTY STATUS WITHDRAWAL FORM <br />f?llin 9 an <br />In the matter of File No. M- 1g/ - ?5 , Permit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: UCCA 'ins rc? V? <br />?ff /? <br />?-Ja a i ?1? p C ,r,, P 44 <br />I hereby withdraw as a parry to this matter. <br />I! I hereby withdraw as a party to this matter and, if the Board holds a hearing, I <br />wish to address the Board at the formal hearing, if held, as a non-parry. <br />(Please note that if all objecting parties withdraw prior to the date set for the Board's <br />consideration of the application, the application may be approved by the Office without the <br />Board holding a hearing. In that event, there will be no opportunity 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a person or an entity that has withdrawn as a party.) <br />Regardless of a party status, the Division thoughtfully considers each issue submitted in writing <br />to the Division and provides a response to those issues within its jurisdiction in the Division's <br />"Rationale for Recommendation." The Rationale is available to any person by contacting the <br />Division. For persons who do not wish to become a party or withdraw as a party in this matter, <br />please contact the Division for information on application status. <br />LAO-el scy& <br />Printed Name 02- 9- C 5' <br />Address L <br />City, State Zip Code <br />zl? <br />1 Qmn . C om <br />W Safd5 <br />E-Mail Address A J <br />Signature <br />9`7 v ) 7 ?/9- Est 2'4 <br />Home Phone # <br />Work Phone # <br />FAX # ? j3? f I <br />Date <br />12