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S;ectinu.l-�Gener:al�nformatinn <br />REQUESTED ACTION <br />❑✓ New <br />0 Amendment <br />AUTHORIZATION REQUESTED <br />❑ Release ❑ Assignment/A•ssumption <br />❑ Partial Release <br />❑ Lease <br />0 Sublease <br />❑✓ Easement <br />0 Use Agreement <br />TYPE OF ENTITY REQUESTING AUTHORIZATION <br />0 Conveyance <br />❑ Other: <br />❑ State Agency <br />❑✓ Federal, Regional or Local Agency <br />p Private — Please indicate if commercial: 0 YES ® NO <br />Applicant Inioormation <br />Legal Name of Lessee/Grantee: Indian River County, Florida <br />Contact Name: Arjuna Weragoda <br />Title: Capital Projects Manager <br />Address: 1801 27th Street <br />City: Vero Beach <br />State: FL <br />Zip: 32960 <br />Phone (1): 772-226-1821 <br />Phone (2): <br />Fax: <br />Email Address: aweragoda@ircgov.com <br />Billing Information. (if same asabove check,tieret n ) <br />Name: Arjuna Weragoda <br />Title: Capital Projects Manager <br />Company: Indian River County Department of Utility Services <br />Address: 1801 27th Street <br />City: Vero Beach <br />State: FL <br />Zip: 32960 <br />Phone (1): 772-226-1821 <br />Phone (2): <br />Fax: <br />Email: aweragoda@ircgov.com <br />Representativ.eDiformatibn: (Only co» mp'lete if someone Wilbbe handling this transaction on your behalf) <br />Name: <br />Title: <br />Company: <br />Address: <br />City: <br />State: <br />Zip: <br />Phone (1): <br />Phone (2): <br />Fax: <br />Email Address: <br />ManagementPlan or Land.Use•P1awContact,Iaforniati.on (for Leases/Sub7eases only) <br />Name: Roland DeBlois <br />Title: Chief, Environmental Planning <br />Phone (1): 772-226-1258 <br />Phone (2): <br />Fax: <br />Email Address: rdeblois@ircgov.com <br />Application for the Use of State Owned Uplands <br />Florida Department of Environmental Protection <br />Page 3 of 6 <br />P20 <br />