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APPI,�C'ATION FOR DEPARTMENP OF THE ARMX PERMIT(33 CFR 325) OMB APpROVAL NO 07t0�iO3 Eipires Dec 31.2�04 <br /> ll�c publie b�u�den fot Wis wllxlioo of infotmatioc is estimaled W tve�10 houis pc reSponse,aljhough the me�aily of applicatiaas�onld teqmra S hours m less, 71tis include9 <br /> •16a tirne ka rev�ewio8 inftrucuoaf.l�lo�exisfini dW souron.l�i�od mainuinina ths dw nad�d,sod oomplaing and mviewin�d�e ooilao�im o[mfo�m�. Sw� <br /> aamments regazaine ihn b,uden akimnc a.ny alher aepea of�hia ameobon oeialbsm.ltoa.mra.aie�g wggesdons for naucc�g mie buram.a oep�elmenl orDefms.wsaliioywm <br /> He�dqunlaa Service Dircctorate of Iot�m�tion Operetiom�ad Raporta,l21 S Jedenaa Davis Hishway.Sui�e 1204,Arlingcoa,VA 22202�1302;pod W tLe O(fw�oF Managemaat <br /> aod Hu�P�psaak R�aducdoo Projeel(0710.0003).WssEdng�am,DC 20303. Re�pond�ls�lo�dd be a�ware Ihat notwidiatanding+i9'MAtr provi�ioa oFlwr,no peaon shalt 6e <br /> �W�y pmdty for failing lo eomply wi�L a collection of infannaaa►if it doa mt disptay a wrrmtly valid 0[�oa�tol n�ber. Pkat�DO N(7f RETUItN your fam b <br /> a�or iha.aed���n... comptowa applicacons mnse ee abnined a�be DiwiC mgir�ccr navinBiurisaicaon over tlro lo�atioo ot me papwea.atvny. <br /> PRIVACI'ACl'Sl'A18NF�VT:Auihaitlm:Rtve�s a�d H�rbas Ad,5alioe 10.33 USC 403:Qat Wrlar Ae4 Sectioc�01,33 USC 134t;Mai�e P1o�eaiao.ReKa�e!md <br /> S�Wrip A4,33 USC 1413,Sacliou 103. Principal Pwpose:ld'u��ion y�pvided on 1hi�fam rnll be wod'm w�tu�oag tha�ppliedion far r pe�mil. Aowiot usm:71ri� <br /> infamviaa ioy bs�herod wilh the Deprlment of,lustia�nd ad�a Fa�derd,etate,�nd local govanms�yaian. Subm;�a;on ofrsqueued ota�m�tioa ia vdunury;6owevs,if <br /> io�ia nglwo�ided.tha nemrt�oolim�im caneot hn erelumed n�ar a oemit�issoed <br /> 1TEM5 1 THROUGH 4 TO BE ErILLED IN BY THE CORPS <br /> [.APPLICA770N N0. 2.F[ELD OFFICE CODB 3.DATE RECETVED 4.DATB APPLICATION COMPLETED <br /> YOU DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADEO AREAS. <br /> Al!applicants must compleu non-ahadcd�tems 3 and 26. [f an a,gent is used,aleo cocnpletc items 8 and 1 l. This optional Foderal fotm is valid <br /> for use oKl when includod as of this erttire sfst� lication ket <br /> S.APPL[CANT'S NAME 8.AUTHORIZED AGHN7'S NAMB AND TITLE(an yeet ig npt requi�ad) <br /> Ml lln�,-ka�K�c �o�A.b l t Or c.d. i n <br /> 6.APPLICArTt"S ADDRB,4S 4 A(3ffi�'�"S A1�DR6S$ Cj00 CS �C 5'tl5t.t't • t�'' <br /> 7.A'PP'LICAM"3 PHONB NO. I0.Af3$M1"3�IONB N0. qrj2 •��L.( -q�,J� <br /> 11.STATEMEN7'OP AU7'RORlZAT[ON(�fa�plleable:car�pkle oalr(J'o�dYwlnbig a�cgentJ <br /> I hereby sulhorine �o aa oa my behelf es my agee�in u►e proassiu�oftliis appiicetion wd lo fiunesh.uP��'e9�. <br /> suQpkmcnlal info�uUaa in supporl of this permil applicstion. <br /> APPUCANI"'S SIGNATURE: DATE: <br /> l2.PRWECT NAl1�Ott YT!'Y.E(ea io�tton�� <br /> I3.NAMB QF VNA'1'P.R�ODY�IF RNOWN(it�ppltaib�c) 14.P1tWELT 3TAB6�'MDRESS(if appWW�ble) <br /> I3.LOCA'i7i0N OFPItQ1,�C'1' <br /> 16.O�fT�Elt LOCAT�OD[b6SCRTe'ItQNS.IF ICNOWN�Esee i�struotioos) <br /> ]7.D�C130iNS 1'0'PP�SPIE ]�.NA7C)RB OB A4TlVf'tY <br /> 19.�1tOJ8CTPf]ItPO�E 20.R8A34N(3)FOR DYSCHARGB <br /> �i.TYPE$OF MATBRIAL BBMG DISCHARQSD AND 7'F�AMOtJNT OF�ACH rYPg II�i CElBIC YARDS <br /> `�Z,SURFA(;E AREA IN AC:RES OF W�'iT.ANDS OR O�R WA'fBRS P11.I.$D <br /> S3.�4 ANX FOR1ZQiN OF�1B WORK A1.R�MY COI�t.SPS? Y$S� NO.Q IF Y$S,DI�SCRIBE OObIP[.L�'f'SD WO�tK. <br /> 24.ADDRBS38S OF AD�On�iuYG pRO�BR'c1r OWr1EItS. <br /> 23.LiST OF O�l'�i$R CBR17l�lCAT10NS OR APP80VAi.$/DLN7Ai,S R£C$[VED F1tOM 07TiBR PBDERAL„$TAT$OR TACAI,AG�NC��OR <br /> WOR�C DE5CRI8SD Hd'f�113 APPI.ICA�iON. <br /> 26. Applicedon is hercby made for a permit or permita to authori2e We work descriDed in tltis appfication. I certify that the infa�nation in this <br /> application is c�mple�te and aocwate. I FuRher catif�that i possess fhe suflNwrity to undeNake tf►e work described herein or am ading as the duly <br /> aut6orizod e�ent oftha applicant <br /> t� ' � f <br /> t'_z a� oy <br /> Sideat fapplicaet n � ipuuro of egeet(if any) bate <br /> 71ro appliostio�must be si6ned by the pasoa who desires W undeetalce the propoaed acfivity(applicemt),or it may be sly�ed by a duly�nthaizad age�t if <br /> Ihe sutemau io Blod�l 1 6�been filled out a�d ai�ed. 18 US.C.3eeBoa 1001 provida tl�t Whoever,in my mmaer wilhin the jurisdiction ofany <br /> dep�ebneet or�y of fhe Uaioed State�lcnowia`ly and wi11fu11y falsifia.conoals,a eove�s up wilh eny trick,scheme,or disguises a ewterW ficl� <br /> mekes aay t►Isa,fictitious or 6andukat ataeroe�ts or rcpresentations or melces or uses ury false writi�`or docutomN knowing�aee lo co�tain eoy faleie, <br /> Acdtfow or Ihudulant�aurneeu or enbry,shall 6e fi�xd not moro�hse S10,000 or imprisooed not mrne then Gve years or bolh. <br /> ENG FORM 4345,Ju197 EDI'I'ION OF F�B 9�4 i3 OBSOLETE. (Proponent:CECW-OR) <br /> Mio�aoo�LocaUSuee/Fedetat Appliption Fo�ms for WatedWeURnd Projects <br /> Pa�e 2 <br />