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y <br /> f <br /> ~ Credit Request Form <br /> ' West Eugene Wetlands Mitigation Bank <br /> Submit the completed form to: Dal Ollek, ATTN: Mitigation Bank Application, City of Eugene, 1820 Roosevelt Blvd., <br /> Eugene, OR, 97402. <br /> Section 1: A icant's Information <br /> la. Applicant's Name I b. Phone Number(s) <br /> j CIT Cu ~vE - r=.UG,ENE ~Ir~o2T may!-(ogZ- Sy3o <br /> ~ Ic. Mailing Address ld. City, State, Zip <br /> Z ~ g SS' Lock~~ed ~2 ~u~,EN~ 02 9 ~-yaZ <br /> le. Email Address <br /> ~ Section 2: Authorized A ent if an <br /> 2a. Agent's Name 2b. Phone Number(s) <br /> 't"E21. I--I J L<G 1 S Sy 1 - (0 8 2 - ~ y to Z <br /> 2c. Mailing Address 2d. City, State, Zip <br /> <br /> I~ Z'-r ~I ~ . ~JroA D w A .f ~ UC.. 9 ~}U ~ <br /> I 2e. Email Address <br /> JE~2-IL, N14GIN~@ CI EU4En.?E,OR,u$ <br /> <br /> i Section 3: Pro ect Location Information <br /> 3a. Street address of wetland impact 3b. City, State, Zip <br /> r~IrPa2T CuG. U2 9'}4(~Z <br /> 3c. Map and Lot Number(s) of wetland impact <br /> I~-GyG'Fioc~o tooU 1'~pyo8voo14o1 <br /> 3d. Project name: n <br /> <br /> i Alt'po~2T 1`oRp lZEf~l.14NYKEl..i i <br /> Section 4: Wet)<and Miti ation Credit Re uest <br /> 4a. Acres of w$tlands to be impacted by project: <br /> <br /> i 91 acres <br /> 4b. How many credits do you want to purchase from West Eugene Wetlands Mitigation Bank? <br /> 3 , 9 1 credits <br /> 4c. By what date do you want to purchase the credits (month/day/year)? <br /> Section 5: Re 'fired Documentation <br /> Submit photocopies of the following documentation: <br /> Wetland delineation report <br /> X~ Oregon Division of State Lands (DSL) letter of concurrence for the wetland delineation report <br /> U.S. Army Corps of Engineers letter of concur: ence for the wetland delineation report <br /> Joint (Fill-Removal) Permit Application <br /> Page 1 of 2 <br /> <br />