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� � � � <br /> Request for Wetland Buffer Evaluation <br /> Property Address: � " v � <br /> Person Making Request: --� `�� r-'-L— �� 'C'�cc:`'rc-� �- <br /> This person is the: <br /> ❑ Property Owner [�Owner's Contractor/Consuitant ❑Other <br /> � <br /> Company Name'1'TE_�G(�1w��1k:�'= �C%�- �-�..�— <br /> Address:��� l-�ti/V/�'QC%1..��_�C� <br /> � <br /> City:�LS..-r��.G�.�� Zip: :�-�'�'� � <br /> Daytime Phone:��v�(���5 ��Cl�� <br /> EmaiL f'�'+r� !�-G�-'�j`�u�'<(,-C� LGM.0 n-��1��� <br /> What work is planned? <br /> ��_� � �� ����1� ��L <br /> � <br /> ignature of person mal request <br /> i��� / � . <br /> Date <br /> Staff use only <br /> Date received: <br /> ❑Two copies of delineation <br /> ❑ Two copies of survey <br /> ❑ Two copies of MCWD acceptance <br /> Date sent to engineer: <br /> Date engineers report received: <br /> Date engineers report forwarded to applicant: <br /> Packet Last Updated: 03/29/13 <br /> Page 18 of 21 <br />