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REOUESTED ACTION <br />M New ❑ Release ❑ Assignment/Assumption <br />❑ Amendment ❑ Partial Release <br />AUTHORIZATION REQUESTED <br />❑ Lease Easement ❑ Conveyance <br />❑ Sublease ❑ Use Agreement ❑ Other: <br />TYPE OF ENTITY REQUESTING AUTHORIZATION <br />❑ State Agency <br />❑✓ Federal, Regional or Local Agency <br />❑ Private — Please indicate if commercial: ® YES ® NO <br />Applicant Inf'6rmation <br />Legal Name of Lessee/Grantee: Indian River County, Florida <br />Contact Name: Arjuna Weragoda 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@iregov.com <br />Billing Information. (ifsame asabove dheck•heret n ) <br />Name: Arjuna Weragoda <br />Title: Capital Projects Manager Company: Indian River County Department of Utility Services <br />Address: 1801 27th Street <br />City: Vero Beach <br />State: FL <br />Zi : 32960 <br />Phone (1): 772-226-1821 <br />Phone (2): <br />Fax: <br />Email: aweragoda@iregov.com <br />Reuresentatiye,Infbrmatibn: (Only corrrolete ifsomeone wilbbe handling this transaction on your behalf) <br />Name: <br />Title: Company: <br />Address: <br />City: <br />State: <br />Zip: <br />Phone (1): <br />Phone (2): <br />Fax: <br />Email Address: <br />ManazementPhin or Land.Use•P1an,Contact.Iaf6rmation (for- Leases/Sub72ases only) <br />Name: Roland DeBlois <br />Title: Chief, Environmental Planning <br />Phone (1): 772-226-1258 Phone (2): <br />Fax: <br />Email Address: rdeblois@ircgov.com <br />99" Application for the Use of State Owned Uplands <br />Florida Department of Environmental Protection <br />Page 3 of 6 <br />P20 <br />