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Name of Fire Protection District: South Teller <br />Name of Electric Providernone <br />Name of Gas Provider: none <br />Date Parcel(s) Created (for Exemption Plat only): not applicable <br />Proposed Zoning (for Zone Change only): not applicable <br />1 DO HEREBY CERTIFY THAT THE FOREGOING REPRESENTATIONS AND ATTACHMENTS ARE TRUE AND <br />CORRECT TO 7HE BEST OF MY KNOWLEDGE. Date <br />Foatar Scott Pr s;d n o the Turquoise <br />Connection Inc <br />~r/t~Y9 zoos <br />Signature(s) of ALL Property Owner(s), the Authorized Applicant, or the <br />Authorized Agent or Representative required. (USE SPACE OVER AS NEEDED) <br />OFFICIAL USE ONLY: FfE RECEIPT <br />Received By: Date: <br />Amount Received: S Check #: Receipt #: <br />