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10/12/07 FRI 10:47 FAQ 952 345 8721 ADMIN 07.]003 APPLICATION FOR DEPARTMENT OFT ARMY PERMIT (33 CFR 325) OMB APPROVAL NO.4710-003 Expires Dec 31, 2004 The public burden ibr this collection of information is estimated to average ] 0 hours per response, although the maiorsy of epphcahons should requtre 5 hours or Less. This includes the time for reviewing instructions, searching eziating data spruces, gathering and maintaining the data. needed, and completing and reviewing the collection. of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions far reducutg this burden,. to Deparanent of Dofcnsc, W ashingtou Headquarters Service Directorate ofinfnm>ation Operations and Reports, I215lefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302; and to the Office of Management and Budget, Paperwork Reduction Project (0716-0003), Washington, DC 20503. Respondents should be aware that notwithstaodiug any other provision of law, no person shall be subject to any penalty for failing to comply with u collection of information if it does not display a currently valid OM H control number. Please DO NOT RETURN your form to either of these addresses. Completed appGcatious must be submitted to the District engineer having jurisdiction over rite ]ocatioa of the proposed activity. PRIVACY ACT STATEMENT: Authorities: Rivers anti Harbors Act, Section l0, 33 USC 403; Clean Water Act, Section 404, 33 USC 1344; Marine Protection, Research and Sanctuaries Act, 33 USC 1413, Section l03. Priacipai purpose: lnfbmratioo provided on this form will be used in evaluathig the application Cor a pemtiC. Routine uses: This information may be shared with the Department of Justice and ofher Federal, state, and total government agencies. Submission of requested information is vnhmtary; however, if information is not provided, the permit application cannot be evaluated nor can a pertt»t be issued ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS 1. APPLICATION NO. ~ 2. F1ELD OFFICE CODE ' 3. DATE RECEIVED 14. DATE APPLICATION COMPLETED Y4U DO NOT NEED TO COMPLETE ITEMS 6-10 and 12-25 in the SHADED AREAS. .4![ applicants must complete non-shaded items 5 and 26. If an.agent is used, also complete items 8 and 11. This optional Federal form is valid _ for use only when included as part of this entire stab. application packet. 5. APPLICANT'S NAME 'W 1 Lt.f'tz~.~ C~~GN-1 8. AUTHORIZED AGENT'S NAME AND TITLE (an agent is not required) 11. STATEMENT OF AUTHORIZATION (lf ttppltcable; complete only if aurhoi-izrng an agent' I hereby authorize to act on my behalf as my agent in the processing of this application and to famish, upon request, supplemental information in support of this permit application. 26. Application is hereby made for a permit or pernuts to authorize the work described in this application. I certify that the information in this. pplication is cotrgJlete and accurate. I further certify that I possess the authority to undertake the work described herein or am acting as the duly u[itorized agent of the applicant. 10 i3~ ~n7 Signature o a li nt Date Signature of agent (if any) Date The application must be signed by the person who desires to undertake the proposed activity (applicant), or it may be signed by a duly authorized agent if the statement in Block 1 1 has been filled out and signed. 18 U.S.C. Section 1001 provides that: Whoever, in any manner within the jurisdiction of any deparnnent ar agency of the United States lmowingly and w)Ifully falsifies, conceals, or covers up with any trick, scheme, or disguises a material. factor makes any false, fictitious or Gaudulent statements or representations or makes or uses any false writing or document knowing same to contain any false, fictitious or fraudulent statements or entry, shall be Cued not more than $1Q000 or imprisoned not mere than five years or both. ENG FORM 4345, Jul 47 EDITION OF FEB 94 IS OBSOLETE. (Proponent: CECW-OR) ~~ Minnesota Local/State/Federal Application Forma for Watcr/Vleiland Projects Page 2 ~ e ~ APPLICANT"S SIGNATURE: DATE: