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<br />STA~DARD '-OF\l 20q (10-87)
<br />Prt'scrib..,: b} Dor CSDA DOT APPLICATION FOR TRANSPORTATION ANO
<br />p,L. 9n-4S~ dnd Federal UTILITY SYSTEMS AND FACILITIES FORM APPROVED
<br />R..glster ....otg... 5-3-3; OMS NO, 1004-0060
<br /> ON FEDERAL LANDS Expires: Mey 31. 1989
<br /> FOR AGENCY USE ONLY
<br />NOTE. Before completing and filing the application, the applicant should completely review this pack. Application Number
<br /> age and schedule a pre application meeting with representatIves of the agency responsible fo,
<br /> processing the application. Each agency may have specific and unique requirements to be met
<br /> 1n prepat1ng and processing the application. Many times, wtth the help of the agency represen. Date filed
<br /> tatlve, the applIcation can be completed at the preapplication meeting.
<br />1. Name and address of applicant (Include ZIp 2, Name, title, and address of authorized agent 3, TELEPHONE (area code)
<br /> ((,(1' if different from Item 1 (Include Zip code) Applic ant
<br /> Authorized Agent
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<br />4, As applicant are you;' I,/'erl( one,1 S, Specify what application is for: (check one)
<br /> -- - New authorization
<br /> a, lndn'ldual a, -
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<br /> - b, = Renew existing authorization No.
<br /> b, - C orpo~Cit IOn Of'
<br /> --- Partnership' AssociatIOn .. ~ Amend existing authorization No.
<br /> e, e,
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<br /> -- State Go\'ernmentiState d, _ Assign existing authorization No.
<br /> d, Agency
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<br /> -- Local Government = Existing use for which no authorization has been received *
<br /> e, e,
<br /> ----
<br /> f. -- f. - Other *
<br /> - Federal Agency -
<br /> ~ II ,h",ci(ed. r(JI"';f'le!e supplemental page ~ If checked. prot,'lde detaIls under Item ,
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<br />6. If an indiVIdual, or partnership are you a citizen(s) of the United States?
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<br />Yes '---' No
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<br />i. Project descnptIon Idescrzbe In de/ad): (a) Type of system or facility, (e.g.. canal, pipeline, road), (b) related structures and facili.
<br />tIes; (c) phYSIcal specifications (length, u'ldth. grading, elc.j; (d) term of years needed, (e) time of year of use or operation; (f) Vol-
<br />ume or a~ount of product to be transported; (g) duration and timing of construction; and (h) temporary work areas needed for construe.
<br />tion. r,4!IQrj-. addu/onal .,heels. If additional space 15 needed.)
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<br />8. Atta,n ~a~' covl2'ring area and show location of project proposal
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<br />4. State or local gDvernment approval:
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<br />Attached ___ Applied for
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<br />Not required
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<br />10. !\onretur:1ablt:" ilpplJ::-atlon fee
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<br />Attached _ Not required
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<br />11.
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<br />Does pr').112' C' crCjSS InternatIOnal boundary or affect international waterways;'
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<br />Yes
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<br />No (/( "yes," indIcate on map)
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<br />12.
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<br />Give state:':";E'nt of }l'Ur technlcal and fInancial capability to construct, operate, maintain, and termInate system for which authotlzation
<br />is being rCJ',le~tf"::L
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<br />fCO'I:/r;uea 'Jr: 'c. ("~,
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<br />299-104
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<br />NSN 7540-01-143-1017
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