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NTY MUNICIPALITY/ APPLICANT ADDRESS DATE FISCAL YEAR BEGAN / / TOTAL ANNUAL BUDGET $ POC NAME Site # (street address, directions from known point, and if available GPS coordinates - provide municipal/township map) UNCOMMITTED BALANCE AS OF UNCOMMITTED BALANCE AS OF POC PHONE Location / / APPLICANT PHONE ANNUAL MAINTENANCE BUDGET $ POC ADDRESS DATE / / Damage, Description and Dimensions (give facility name, length-width-depth-sf-sy-cy-tonsnumber of items, etc.) Local Estimat.

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