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<br />5, NAMES AND AOORESSES OF ADJOINING PAOPEATY OWNERS. LESSEES, ETC" WHOSE PROPERTY ALSO AO.K>INS 1liE WATERWAY <br /> <br />See attached list of land owners. <br /> <br />8. WATER8OO't' AND LOCATlOH ON WATEA800Y WHERe ACTlVrTY EXISTS OR IS PROPOSeD <br />The Red Mesa Dam and Reservoir is located on Hay Gulch, a tributary of the LaPlata River. The <br />existing facility is located on the Mormon Reservoir USGS 7.5 minute quadrangle map. <br /> <br />7. LOCATlON ON LAND WHERE ACTMTY EXISTS OR IS PROPOSED <br /> <br />AOORESS: <br /> <br />Sections 22 and 27, T34N, R12W, N.M.P.M. <br /> <br />STREET, ROAD, ROUTE OR OllER 0ESCRIP11VE LOCATlON <br /> <br />COUNTY <br /> <br />STATE <br /> <br />ZIP cooe <br /> <br />LOCAL GOVERNING BOOY WITH JURISDICT10N OVERSfTE <br /> <br />8, Is any porllon 01 lhe acllvily lor which authorlzallon lalOUQht now complel8? 0 YES 0 NO <br />If anawet .. -w-- giw rNlON, month end yew the activily w.. c:ompIeted. Indicate the uisling work on the drlWings. <br /> <br />8, List'" lIppI'ovllls or c:ertilications end deniIIIa receNed horn ott.' 11IdlIr", Inter...... ..... or local agencies lor any IlrucluI8I, COI'IItruction, dischalgea or other <br />IIClivities described in lhis applicalion. <br /> <br />ISSUING AGENCY <br /> <br />type APPROVAl. <br /> <br />IDENTlFICATlON NO. <br /> <br />DATE OF APPLICATION <br /> <br />DATE OF APPROVAl. <br /> <br />DATE OF DENIAL <br /> <br />10, APPllC4lion ia hereby made,or I pwmil or pwmll. 10 aulhor",. lhe IClivihN deacribed '-.in, I cerli/y lhall am lamillar ..ilh lhe inlormalion con18ined in lhe <br />aPPlicalion. .nd lhal 10 lhe beal 01 my knowledge and belie, such IIll0flNllion ia Irue, cunplel8. and lCGUIale, I luru- ~h/y lhal I possess lhe aUlhorily 10 <br />underlaloa lhe proposed lIWviliel or I .m IICling .. the duIV eulhorized agenl 01 the applicant <br /> <br />/rfJd~. <br />(1 SIGNAtuRE <br /> <br />j- 2../)- 95 <br />DATE <br /> <br />g~ dlI~ <br />SIGNATURE OF AGENT <br /> <br />~/{( crs <br />. DATE <br /> <br />The application must be signed by the person who desires 10 IIIIderfalla /he proposad activity (applicant) or it may be sign ad by IJ duly, <br />authorized agent tf the statament in blocJc 3 has bean filled out and signed. ' <br /> <br />18 U,5,C. 5ecbon 1001 providaa Ihat Whoovef'. in any fTIaMtJ( wilhln Ihe jurisdiction o. any dopal\lTleol Q( agency o. The Un.ted SIaI8a <br />knowlOQly and willfully IaIslll6S. cooooaIs, Q( oovars up by any tnck. scheme. or dfMce a material 'act or mak8a any false. hClIlIoua Q( frauduleot <br />slal8menlll 01 ropl'868rltaloOr\ll 01 makes or uses any falSe Willing or ~t knowiog same to conl&ll any lalse 1ic1llKlu8 01 <br />tr auduleol sta\emenl 01 entry, ahaIl be r~ not mare It\an $10,000 Q( impnaooed not mare lhan live ye.vs, Q( bartl. <br /> <br />'If....... oIlNO fOR" 41411 <br /> <br />.u,s, ao..,M*1I Pmtl"ll 0lIIce: IIIlII - 626-23614000 I <br />