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i 7- Cont'd from pg 2. Application Evaluation Review Sheet Applicant Name: App#11, W. C. Graves III Address: IP.O. Box 998 Vero Beach, FI. 32961 Tract Number(s): Field Number(s): I All in I.R. County Date: iNov. 16, 2002 Vl tteview Suimma Land Use/Field: Acres: Micro-Irrigated Citrus Grove 593 Best Management Practices Applied For: 4. Portable Agrichemical Mixing Station. Total BMP Costs: rL 160%Cost Share: Div By Total Eval Points: =Applicant's Score: Applicant Cost: $8,612. $5,167 20 258.36 $3,445 VII,`ttemarks: Vill. ` dsi nat fChCO fVatibnist:_ cy- (Signature) Dat . (Checked By) Date: - -/3 -0� IRSWCD Board Approval > Date 74-r (Applicant Signature) Date Privacy Act Statement: The following statements are made in accordance with the Privacy Act of 1974(5U.S.C.522a). 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 furnish correct, complete information will result in the withholding or withdrawal of such technical,educational,or financial assistance. This information may be furnished to other USDA agencies,the Internal 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)