2018-12-10_REVISION - M1997026

• Permit No: M1997026
• IBM Index Class Name: REVISION
• Doc Date: 12/10/2018
• Doc Name: Application
• From: Oldcastle SW Group
• To: DRMS
• Type & Sequence: SO2
• Email Name: SJM
• Media Type: D
• Archive: No

NOTARY FOR STRUCTURE OWNER WITHIN 200 FT OF 5 MILE PIT AFFECTED AREA
ACKNOWLEGED BY:
Structure Owner Century Link Name
Date osrkto Title L112NIV4CT A- Un
STATE OF )
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COUNTY OF )ss.
The foregoing was acknowledged before me this. �day of ,20A,by
as 0
My Commission Expires:Q '�� th��>
ry Public
L WELLBORN
Ncray v,a-c-CaMa�a
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Carp U4P%0215M
My C",Ex2o"Jul+0.2W0