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40 <br />40 <br />CI <br />Page 2 <br />Grant Number, nrnn 29 Payment Request Number <br />In requesting this payment the undersigned represents that he/she Is duly authorized to <br />act on behalf of the recipie <br />/�n <br />'jjt. <br />^- Q C)CLa"," January 18, 2404 <br />Signature of Authorized Representative (Not Stamp) pate <br />IRAN B. lslWAMS, CHAIRMAN <br />130ARD OF COUtM CX7hMSSIONSRPlease return original to: <br />Department of Environmental Protection <br />Solid Waste Section - MS# 4565 <br />2860 Blair Stone Road <br />Tallahassee, Florida 32399-2400 <br />5199 <br />1-Llr <br />