07/15/2004 Env Bd Packet - Laserfiche WebLink

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, J APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT (33 CFR 325) OMB APPROVAL NO. (RENEWAL PENDING) It The public burden for this collection of information is estimated to average 10 hours per response, although the majority of applications should require 5 hours or less. 1 This includes the time for reviewing instructions, searching existing data sources. gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this en, to Department of Defense, Washington Headquarters Service Directorate of Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, lington, VA 22202 -4302; and to the Office of Management and Budget, Paperwork Reduction Project (0710 - 0003), Washington, DC 20503. Respondents should be tware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not 1 display a currently valid OMB control number. Please DO NOT RETURN your form to either of these addresses. Completed applications must be submitted to the T District engineer having jurisdiction over the location of the proposed activity. l •; PRIVACY ACT STATEMENT: Authorities: Rivers and Harbors Act, Section 10, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research and Sanctuaries Act, 33 USC 1413, Section 103. Principal purpose: Information provided on this form will be used in evaluating the application for a permit. Routine uses: This information may be shared with the Department of Justice and other Federal, state and local government agencies. Submission of requested L information is voluntary; however, if information is not provided. the permit application cannot be evaluated nor can a permit be issued. i ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS. 1. APPLICATION NO. 2. FIELD OFFICE CODE 3. DATE RECEIVED 4. DATE APPLICATION COMPLETED YOU DONOTNEED TO COMPLETE THE SHADED AREAS. A//_applicants need to complete non- shadeditems 5 and 26. If an agent is to be used, also complete items 8 and 11. Thus optional Federal form is valid for use onfrrwhen included as a part of this entire state application packet. 5. APPLICANT'S NAME Ed Vaughan 4-1 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required) Ron Peterson . 11. STATEMENT OF AUTHORIZATION (if applicable; complete only if authorizing an agent) - thereby authorize Ron Peterson to act in my b alf as my agent in the processing of this application and to furnish, I '' upon request, supplemental information in supp e • . s • ermit ap lication. APPLICANTS SIGNATURE: - DATE: 5-1/-0 1 .ft _( 26. Application is hereby made -� appli • omP to and ,z • the ap r a permit or permits to authorize the work described i • •plication. I certify that the information in this ate. I further certify that I possess the authority to ertake or' d herein or am acting as the duly t. ti ignature of appli Date Signature of agent (if any) /zy1 Date FThe application must be signed by the person who desires to undertake the proposed activity (applicant), or it may be signed by a duly authorized agent if the statement in Block 11 has been filled out and signed. 18 U.S.C. Section 1001 provides that Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly and willfully falsities, conceals, or covers up with any trick, scheme or disguises a material fact or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both. ENG FORM 4345, Jul 97 EDITION OF FEB 94 IS OBSOLETE. (Proponent: CECW -OR)