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J1ALL V1` L, ~JL ViV^1/tJ <br />III IIIIII!IIIIIIIII IVI'--ED LAND RECLAMATION: ARD <br />ARTY STATUS REQUEST FORM <br />In the matter of File No. M- 70-~ Permit/Permit Amendment Application. <br />Name of Operator/Applicant and Site: / ou r srana Lait~ wit ~ l rayt~ L L r . <br />I request that I be named as a patty <br />I request that I not be named as a party <br />X I request to be withdrawn from party status <br />~eceived <br />/ ~~~ <br />ohs. ' G%u~u~ ~ 0 <br />o~o~~~ X00 <br />pt~rago ~id oni~e <br />Division o1#`r rats 8 Geology <br />I understand that if I am not a party, my statements of concern or objection o this <br />application will not be considered during the review of the application, but I may address <br />the Board on this matter at the final hearing, and may present my concerns as an <br />interested member of the public. <br />For people who do not wish to become parties in this matter, information on permit <br />application status can be requested from the Division of Minerals and Geology. <br /> <br />Printed Nar4te - - <br />Y _$~ <br />Address //,~~ <br />City, State Zip Code <br />Home Phone # <br />Work Phone # <br />FAX # <br />E-Mail Address <br />Signature ~- Date <br />If you are requesting to be named as a party, please briefly describe below: <br />1. how you may be affected or aggrieved by the Board's decision in the matter referenced above, <br />2. your opposition to the matter, including a specific description of the issues that you feel need <br />to be addressed at the final hearing. (You may attach a written statement to this form instead <br />of using the space below.) _ _ <br />~~~~~~ ~~~9~~ <br />~lL~ <br />~IL~ ~®~V <br />