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RECE V <br />JUL 25 2011 <br />Division °I rleciamation, <br />Mining and Safety <br />STATE OF COLORADO <br />MINED LAND RECLAMATION BOAREP /4".r$P) P <2 <br />PARTY STATUS WIT)JDRAWAL FORM : c/ <br />� f /$ of � <br />In the matter of File No. M- � , Peri�iitlPermit Amendment Applicatio�Y. G <br />Name of Operator /Applicant and Site: (A)- Or - 0 A AAN" <br />�- F O <br />I hereby withdraw as a party to this matter. <br />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 -party. <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a person or an entity that has withdrawn as a party.)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 />f7 t LE& <br />Printed N e <br />Address ^ 4kX v ( , 73 q' <br />City, ' Sta dl r Zip Code <br />E -Mail Addres <br />Signature <br />12 <br />( ) <br />H P one # O7 �!� 7 <br />Work Phone # / <br />( ) <br />FAX # <br />Date <br />