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w1� Cont'd from pg 2 . Application Evaluation Review Sheet Applicant Name : Appl . #300 : Custom Herbicide Applicators , Inc. Address : 15901 Orange Ave , Ft . Pierce , FL 34945 Tract Number(s) . Field Number(s) : All in Indian River County Date : I Nov . 7 , 2003 ; 77 Land Use/Field : Acres . Citrus Groves 3657 Best Management Practices Applied For: 3. Precision Application Equipment (4 pieces of equipment). Total BMP Costs: 53.92% cost share Div by Total Eval Points: Div by Acres, times 100 = Applicant Score Applicant Cost: $83 , 332 . 00 $441929 80 15 . 36 $38 ,403 Y w N " • �" � yx Ar V 1} Av k 14Y 4 y too"{/a 12- L �i�4� t (Signatu ate: Ch By) Date: I WCD Board ApVqval Date Z 12, 10 (Applicant Signature) D to Privacy Act Statement: The following statements are made in accordance with the Privacy Act of 1974 (SU .S .C . 522x). The authorities for requesting the information to be applied on this form are: 16 U .S.C. 590a-f (Soil and Water Conversation); 16U .S.C. 3801 et seq. (Food Security Acto of 1985, as ammended) , and the regulation promulgated theruder. The information requested is necessary for the evaluation of an application , development and implementation of a conservation plan as the basis for satisfying program eligibility and compliance requirements, and for providing technical education, or financial assist- ance under the previously mentioned authorities. Furnishing this information is voluntary; however, failure to fumish correct, complete information will result in the withholding or withdrawal of such technical, educational, or financial assistance. This information may be fumished to other USDA agencies, the Intemal Revenue Service, the Department of Justice, or the other State or Federal law enforcement agencies, or in response to orders of a court, magistrate, or administrative tribunal. IRSWCD Page 3 (10-26-01 )