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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />J.R. SMITH, CLERK <br />5. FEID No. (a.k.a. Tax ID#): 59-6000674 Seq No. 075 <br />6. WORK PERFORMED BY: (Select only one) <br />Grantee ONLY <br />Subcontractor ONLY <br />X BOTH the Grantee & Sub -Contractor <br />To Be Determined <br />7. SUBCONTRACTORS CONTACT INFORMATION: (If applicable & known) <br />Organization Name: TBD Following Applicant's RFO Process <br />Name: <br />Title: <br />Address: <br />City: <br />Zip Code: <br />Area Code and Telephone Number: <br />E-mail Address: <br />8. PROJECT LOCATION: <br />A. List of County(ies): Indian River County (please see Attachment No. 1. Map o Project Area) <br />B. List of City(ies)/Town(s)Nillage(s): N/A <br />C. State Lands Lease Agreement Number(s): N/A <br />Provide lease agreement number(s) for any work that will be performed on State Lands. If work will <br />not be on any state lands, please indicate N/A. <br />Remainder of this page intentionally left blank. <br />Attachment 3, DEP Agreement #: R2114 <br />2of10 <br />Rev. 9/26/2019 <br />