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By signing, the undersigned certifies that he/she has read and understood the submittal requirements outlined, and that he/she understands that omission of amy listed item may cause delay in processing the application. 1 (We), the undersignes, acknowledge that the information supplied in this application is complete and accurate to the best of my (our) knowledge. OWNER (Also the Applicant? ? Yes /_ No): Name (print):Meg Blanchet Phone:541-915-8649 Address 2905 Adams St City/State/Zip:Eugene, OR 97405 Signature:Netanket APPLICANT / APPLICANT'S REPRESENTATIVE (Check one): Name (print) Lloyd L Tolbert, LS Company/Organization:Tolbert Associates, LLC Address:P.O. Box 22606 City/State/Zip:Eugene, OR 97402 Phone:541-359-8426 E-mail (f applicable): loyd@tolbertassociates.com Fax: Signature: APPLICANT'S REPRESENTATIVE Name (print): Company/Organization: Address: City/State/Zip: Phone: Signature: / DESIGNATED CONTACT PERSON (Check all that apply): same as representative E-mail (if applicable): Fax: