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<br />/1994 ~1:25 90247~~11( <br /> <br />:AM~.Ll...;ANA <br /> <br />t-'~ l::l.=.I <br /> <br />AlPLICATION FOR DISPLAY OF FIREWORKS <br /> <br />This /0..... is 10" lhe co""""i8~ ofrhe ululng body, c)ther ~ and lor letters may be acceptable, <br /> <br />Name of .ppticat (Sponsorial 0rpIl1...ff<m): <br /> <br />Mr. Teny Sweeney <br />City of Centerville <br />1880 MaiD StlWt <br />Centerville, MN !lS038 <br /> <br />NlUDe of authorized agent of applicauv' AMERICANA FIREWORKS mSPLA Y CO. <br />P.O. "Anv 0456 <br />P"'....d!rinr MN 55331-04.5..6 <br />puom 9520415-3978. FAX 952-470-2117 <br /> <br />Date 01 dhpbty: AUGllST 2.2002 <br />Tillie of diaplay: DUSK <br />!Maden of dBl'lay: LA- IVlof/:.a.. ~~ fL,- <br /> <br />MaImer alld plaCe of sto.... of fir_orks prior tG dhplay: No ~ dellvered de., of the <br />~ <br /> <br />Type aDd \I._bel' of fireworks to be dbdaa~: i~ to 4" - 5" aerial displav .hells. <br /> <br />Name of superviJiu, operator: IR.Onaro Rnnander OR OTHER LICENSED OPERATOR <br /> <br />C..U~..teNo.: 80161 <br /> <br />"* Slpllt1lre of applicant (or lIIlent) Date: <br /> <br />~ . r}' ~ luchlde4: <br />w.-lY wI. ~J..' ~l.) Proof of certl!QUe of insurance <br />~"' tjJ,'r 2.) , DiapnofplUllds <br />_ it)1Iessi~~A, ',1 1~8 , ofageOl'older , <br /> <br />{igDatutf!:~~ Date t/~l/ Zco<.. <br />;/ COpy <br />MAlL OR FAX TO: AMERICANA FIREWORKS <br />FAX 9521470.2117 <br />P.O. Box 0456 <br />ElWClsior, MN 55331-0456 <br />