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Home My WebLink AboutLeone, Kirk 87329C911122,8:56PM .rrthdzed ry t}rc Stac of Nordr Carolina NCAC lkant Name ttss re# Departnrent of Eruircnmtal Qrnlity and Codtal f] nru"-a,ua. flgqScAMA n DREDG E &F flq@hon I5qFTERAL PERM!TT+'?\ EII nl{€",/ (moamcation flComplete Reissue [hrtial 134 pond drive modificationjpg Autlprized Agent Proiect Loc*ion (Conty): Str€.t Addrcsqrs@ RmdlLot #G) clq/ AB Prevlous permit Date previous permit tssu€d in il arE of wiffital cms purs@t to: Pemit fule milable a the folloring lir*c w.@rccq\r/CAHAnies xq w3ag o, ZP il sd flcw M* {s): floer ni* tv*ttQ pilA: M"^ [-luw ^ t*"*, fur)"i'#;,fu,*Sarr/ , @8\-) crooectlrai.wtr. goq +WvQ lll ltg. Irsn*r flrs flnrs : of Project/ Aaivfi; Y ,(Scale: / ,r,r,t".-Lt l5F?E- :ryetatt r-14 (bX?t eline cr tength rr pier(s) 'Platiomarea - r lengthfi - L 0t a* L t e* - Jistance ofBhore iwater/sill - distance/lenrth a r, channel c yards cmp --n r e4 alil :bserved: rtorium: nla hotos: ?n Wbiwr Attached: :Cing yes yesp by, no be rit surtement on brck of mittt Sknature#ntry bbdax TAR/PAH/NEUSE/BUFFER (circle om) n See ncte on Urk regarding Riwr Basin rules [-l S* "afrti r*l notes/@nditims m back toleJaL APPLY 0 ( LeJ https ://mail.google.com/maiUu/O/#inbox?projector= 1 r-rED.E-Expiration Datb 1t1 ation Fee{s)oe*'r/uoney oruer I dd'l I , ftEiiltffi=;Eil#ffi*SII ENew (Modification lComplete Reissue flpartial Reissue AB Previous permit Date previous permit issued the- Coastal Resources Commission in an area of environmental concern pursuant to:\- [[Generat Permit fuiles available at the following link: www.deq.nc.gov/CAMArules-7\ a uthorized by.the Sate of Nonh Carolina, NCAC licant Name reSs re# il Depanment of Environmental Quality and {-l Rules atachea. ztP e g/,W,!rrl CIW CLl VB|DL ztP :ted :(s): yeslrQ cw M,, LJIHA PNA:ves/@ M'^ L-luw Ert IsnrnneOEA 'l: : of Project/ Activity _ , 'ss Length /trr^ Ardu,..r (Scale: / {dock) lenah - -- rpr.,ro,.,Lr T5f,F-- :nge'"fiorn1r1 (bry d-d:r pier(s) 1,, 0I v e*o e* ,J Platform area r lengthfi \-- read/ Riprap lengh - Jistance offshore kwaterAill distance/ r, channel c yards ramp I , )h t w btH :bserved: rtorium: n/a 'hotos:ian Waiver Attached: iding yes yes rit @ 0 no b€by, f TaVmmINEUSVBUFFER (circte one) l_l se" note on back regarding River Basin rules [-l See additional notes/conditions on back 0 I lni6al)OF cRc THAT APPLY AND or PRINTED *"jliffEompliance statement on back try ation Fee{s)CheckS/Money Order lssuing Date Expiration II9 W 3^q - -U L' o-w I eline Length I ADJACENT RIPAR|AN PROPEBTY OWNER STAIEIENT I h6r€by certify that I own prop€rty to l,Lte of Property Ormer) property locatad at lw-Th e- on n)(Addross,Block,*1..1.'L S N.C. (Waterbody)(Clty/Town and/or County) DESCRIPTION AND'OR DRAWING EF PROPOSED DEVELOPTENT t { r- irr- ) ' h-ezR lo g't-20 ,n belou or d,rch a plte &aulng) )F I o 0 .+ ehls o st N t I I wFro 5e- (e-> l( 4; R( must be s6t me. (lf you LL A u,- g Ll lunoerstdh-aGtapier,dbck,,oonnnffi*.boathouse,rrn,oidioin back a minimum distance of 15'from my arEa ol riparian accass unb$ waived by wish to waive the setback, you must initial the appropriate blank below.) I do wish to waive the 15' setback requirement I do not wish to waive the 15' setba$k requiremenl. (Property lnformeton) f tLlL L6;o ^ e-- ftrner lnformadon) "J Evnv'.r L.'p "iryyw ) Drtu! "rf+qgffr. R<,, [" N (. ?S -3 RECEIVED tryfl Nama At, AddrBss x. 1,. N . Z16oj Cfu/$ata/Zip'{ lt t+ZL Tel€f,hono Number6 zz' 27 JUN 2 0 2022 (Rav*td 6tlm012) DCM-MHD CIT\, Dote 4zz1 q Date tn Tho applicant has described to me, as shown bdlor/, the dovelopmsnt proposed at the ebove location.\ I have no objedion to this proposal. -------- .-,, -liavolhidions to this propnRtl . --- t- G 22'L? ^\y AD.TACENT RTPARTAN pROpEFTy OWNER STATEmENT I hereby certify tfiat I own property adjacsnt to K,o,P-I oo*t'z N)of Property Owner) property located at lv n)(Addross,Bloch l. .lr'ln L o ^t1 s N.C. (Waterbody)(CltyIlown rnd/or GountY) DESCRIPTION AND'OR DRAWNG PROPOSED DEVELOPTENT(tndv{rd r- irr- .) , h-e"R lo'9.-2,o tn betow or abch a site dnvlng) \ ) b--> e l*i (! F I o L' +?h 1 (lI S ( Y : ? 1 I t R ( tL 5,e a u-e t.l I do not wish to waive the 'l $ setba+k r€guiremenl. F (Propefi lnforme0on) t,t t- Lgo n e-- Plope$lnformaton) ( or Name L.'o .Ugtlhlg Address Lgr.?,<. h N .L. z1(e3 ll Telophone NunberA 22,22 tulaiting Z&J/L Number -2f/7 RECEIVED (^'*.ffiffT|1,nt Dqte 4zz1 Dote 1r'e- on t Th€ applicant has described to me, as shorn bdlol, ttre deroiopment prope€d at the above "lqcation.\ lhave no objet*ion to this proposal. ---- lhsve obiectifuB to thh prafae.l . lunderstiird-thatapier,doct,.oonnffi*;,boathouse,rn,oibioinm'',iitueset back a minimum distance of '15'from my area ol riparian accsss unless waived by me. (lf you . wish to wawe the setback, you must initial the appropriate blank below.) D -\1 I do wish to waive the 1 5' setbac* reguirement. DCM.MHD CITY ! DREDGE & FILL New E Modification ! Complete Reissue tr Partial Reissue Ng 87329 Previous permit Date previous P€rmit issued D,o l,t/t 1 Stare I5A NCAC Applicent Nam6 Oepartment of Envlronm€nul Qurlity and Resoorces Commssioa ln an 3ea of enviroomedel conc"n Purtuant to: ! n u nta+ea.G€.Eral Permit &16.'.railable at fofiowinS link: Authonu ed A8€nt Proiect Lo<atlon (Crtrnty)r ztP Str€€r P CitI Phone # City PTA nrtt Adl wt' BodY E *, closest Maj. wtr Eody k)Arlected AEC(s): ORW: ye cw Eo*v"f t5 PNA: 5PIMA 0 ,$ I * Type of Proiect/ Activity Shoreline ten8th Accesi Length Pie. (dock)length tixed Platfo.m(s) (Scal AJod'eot' RECEIVED JUN ,0 2022 DCM.MHD CITY FloatinB Platform(s) Total Platform area Groin l€fl8th/fl Bulkhe.d/ Rip.ap hn$6:- AvB dlira,lce ofhhore _- Ereakwater/Sill Max distance/ length 8asin, channel Cubic yards Soat ramp Boathouse/ Ev6Eeach Other nt A buildinB permit/ ir itions SAV observed: Moratorium: n/a Site Photos: Rip.rian Waiver Atlached: fl TAR/PAI''i/NEUSE/BUFFER (circlo dte) See note on bacl r€gardlnS River gasin rules See additional noterconditiont on back \hl (ant PRINT OF LES D THAT APPTY TO THIS PROJTCTAND D SiSn ':yl ) Fee(s) r€ad compliance statement on beck Checl {/Money Order lssuinS Date 0 Expiration Date ENERAL PERMIT FinBer pie(5) .,0\-- ru 3 I-ffi l/- .}91lr2 tr DREDGE & FILL ENER/AL PE New f,Modification tr RMIT Complete Reissue E Partial Reissue of Environmental Quality and l-l Rules attached. ztP Date previous permit issued ----Resources Commission in an area of environmental concem Pursuant to: General Permh Rules ayailable at link: Authorized Agent Proiect Location (County): City Adi. Wtr. Body Closest Maj. Wtr. Body N9 8732e AB Previous permit RECEIVED D fu authorized I5A NCAC Applicant Name City Phone # Email Affected AEC(s): E.* Eo*!selrvrn f''s Iews EW PTA UW OnW:Ves/nfl Type of Project/ Activity Shoreline Length Access Length PNA: I Pier (dock) length Fixed Platform(s) Floatirg Platform(s) .-l Finger pier(s) Total Platform area Groin length/# Bulkhead/ Riprap Avg distance offshore Breakwater/Sill Max distance/ Basin, channel Cubic yards Boat ramp Boathouse/ Beach Other SAV observed: Moratorium: n/a Site Photos: Riparian Waiver Attached: A building perm lensth ,$ I * PU ^,0 C[44[. EVts'I JUN 2 g Ll,?? DCIII-MHD CITY yes yes A(57 ,fr no no TAFVPAM/NEUSFJBUFFER (circle one) See note on back regarding River Basin rules See additional notes/conditions on back )o State it* * PROJ AND re t Appl Fee(s) read compliance statement on back of perm Check #/Money Order lssuin8 Date Expiration W l/-W, T tq:yi-uJr--It-r r lltr t tU^ AIUACENT RIPARIAN PROPERTY OWNER STATEIEIIT I horeby certify that I ovrr property adjacent to I,LP- 1.,-u- property located at N)lv (l{ame d Property otlner} I ne- on t)h ) (Addrsss,Block S ) in L o r,.1 t.N.C. (Waterbody)(CiSIown and/or Gountyr) The applicant has described to me, as shown bdlor, the development propos€d at the above b<Uon. \ I have no otrjedion to this proposal. DESCRIPTION AND'OR DRAWNG PROPOSED DEVELOPIENT .K (tnalaia c iet- ) . h-a,.\<- lo'sr-20 below or tuch a sie &aviog) \ ) b'-> tn l.t li6 wch 1 ds R 4t I understand-that a pier, dock, ,noonnnffiP,o**, boathouse, ftft;or g;;in must ue-iet Dacx a mmrmum distance of 15' from my area o{ riparian access unless waived by me. (lf you wish to watve the setback, you must initial the appropriate blank below) LL v 5'<-a u-- s Ll (Property Owner lnformaton) f ,LtL L6o ^e- t'*ToJEvnuu Name Print or Ws D,,\,(=F :7 .$lnryAcl&essKaLz x. l^ N .L. ?16ojcwwL. T@hone Nwnber6.22, 27 (t ka,L N(. -? 6 22, ZL JUN 2I 2022 (Revrtd A1V2O12) DCM-MHD CiTY Dde 4zz1 Date ----- -- , ---lhave obieciions to this+mpaeel . f,tt R( I do wish to rrvaive the 15' setback repuirernent. _.-- I do not wish to waive the '15 setbafl< requiremer{. lnfonnetion) 4ddless tt L.',p RECEIVED ADJACENT RIPARIAN PROPEhW OWNER STATEIEI'T I hereby certify hat I own property adjacent to r 0-)2 ,)i,., d Property Owner)propefi located at-Th e- on Or'!) S (Addtrss,Bloch IN L ) l."L N-C. (Waterbody)(CitylTown and/or County) The applicanl has described to me, as shorrn bdlow, the de\clopment proposed at the above \cation.\ I have no otjedion to this proposal. DESCRIPTION ANIYOR DRAWNG bF PROPOSED DEVELOPf, EIIIT(tn&ldud r irr- ) . he"\<_ lo'g't20 tn Fr G F I o a 4 eh 6 Y B beJov or atlach a sitb &awing) R( must be set me- (lf you w I I L(i 1d b-- R I understand-that a pier, dock, ,oonnnffiffio, boathouse, rrft, or groin back a minimum distance of 15'from my area o{ riparian access unless waivea uy wrsh to watve the setback, you must initial the appropriate blank below.) $'ea t--g Ll D-H ldo wish to rraive the't5,setback repuirement. -- I (b not wish to waive the 't 5 setba$k requiremer{- (Property Prcperty lnformdion) €f ,LL LE.o ^e_Name u)L.op .rblfrtg AddesslLAlq *, l^N t. z't CfulsiatetziDa lq qzL- Tei€,phone Number(- 22,22- ZSJrZ .-2f/7 ECEIVED B*fffff$1ozt Dde 4z-21 6'0j Dae -- --@riiproprrsal .-- iD lnfonne$on) DCM-MHD CITY ,VCAMA ❑ DREDGE & FILL 7 1,a,, N9 '8'73aq A B CD GENERAL PERMIT Previous permit Date previous permit issued ❑New Xmodification ❑ Complete Reissue ❑ Partial Reissue uthorized by the �Sta.tye of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to: _f NCAC 4-acoo ❑ Rules attached. General Permit Rules available at the following link: w vden.nc goy/CAMArules LOY, r!J i iI cted ❑CW :(s): ❑OEA is yes/C of Project/ Activity _ w ellne Length 9 PTA ❑ ES ElPTS uW ❑SPIMA ❑PWS (dock)length i Platform(s) 5ng Platforms) tr pier(s) . IPlatform area i length/p head/ Rlprap length iis[ance offshore kwater/Sill �— distance/ length,=�_ t,channel c yards ramp house eo tlifi , h Build ��ing r �1 QJL observed: yes o itorium: n/a yes o ! 'hotos: an Waiver Attached: 2b no n i Iding permit/zoni9g permit may be require or THIS Street Address/State Road/Lot #(s) SutAivislon I�� J City ,� Adj. Wtr. Body t Closest Mal. Wtr. Body IV� . / al T— ❑ TAR/PAM/NEUSE/BUFFER (circle one) ❑ See note on back regarding River Basin rules ❑ See additional notes/conditions on back ation Feels) compliance statement on back of p rmit•• Si nature 11 Check 8/Money Order Issuing Date Expiration Date ADJACENT RIPARIAN PROPSv2TY OWNER STATEMENT I hereby certify that I own property adjacent to K 12 C eoN're --'s (Name of property Owner) property located at o t V J r) V t "(he, (Address, L t, Block, Road, c.) on J> r) in l ra ✓.} � N.C. (Waterbody) (Cityrrown and/or County) The applicant has described to me, as shown billow, the development proposed at the above location. � I have no objection to this proposal. • .3 1 oWN #11 DESCRIPTION AND/OR DRAWING F PROPOSED DEVELOPMENT (individual proposing development must fill in Ides rlptfon below or attach a site drawing) h� (0 v o �� 4 N G 17 t- _ WAIVERS CTION I understand that a pier, dock, mooring pilings, bileakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my area o1l riparian access unless waived by me. (If you wish to waive the setback, you must initial the appropriate blank below.) I do wish to waive the 15' setback renuirement. I do not wish to waive the 15' setback requirement. (Property Oygper Information) L6o n 7g�Z.�`aWt,�-� r Arras �on flln Address - ��Ki1 N.4,. �2 Go CAM"V041 t5 y.z,z, Telephone Number 22. 22.. Date Owner information) Signature B `p EU A V\t EIVED v 22 ZZS Date JUN 2 9 2022 (Revised 611812012) n DCM-MHD (,ITV ADJACENT RIPARIAN PROPE� TY OWNER STATEMENT I hereby certify that I own property adjacent to ( eor� .r— Is (Name of Property Owner) property located at d )y �� /' 1 v t 'The (Address on Pon d _, in (Waterbody) 11rel The applicant has described to me, as shown bdlow, the development proposed at the above _. cation. I have no objection to this proposal. 1 . 009 DESCRIPTION AND/OR DRAWING F PROPOSED DEVELOPMENT j (Individual proposing development must 11/1 in fides ription below or attach a site drawing) i1 99 A 1 ( Llft 6 f 4- (a y K ` r Ste'-- ✓J �.v' � G WAIVERS CTION _ I understand that a pier, dock, mooring pilings, b eakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my area oq riparian access unless waived by me. (if you wish to waive the setback, you must initial the appropriate blank below.) iD-)i I do wish to waive the 15' setback requirement. I do not wish to waive the IV setback requirement. (Property erInformation) Signature f or ype Name n ('Pwa Adalline Address C /State/Zi tq �LZ- yzz Telephone Number ZZ 22. Date Information) �e)A TeMphqnwumber r19 120 .-25l / Date RECEI\/Et? (Revised ;6/f �09270?? DCM-MHD CITY ❑CAMA ❑ DREDGE & FILL GENERAL PERMIT New []Modification ❑ Complete Reissue ❑ Partial Reissue No 87329 Previous permit Date previous permit issued A B C D As authorized by the State of North Carolina, Department of Environmental Quality and th Co tal Resources Commission in an area of environmental concern pursuant to: i I SA NCAC ) ❑ Rules attached. General Permit Rules available at the following link: wwwdeq nc Pov/CAMArules r Applicant Name Address - / / ) ( /. city `I's ! I f' I jI I i State = / ZIP Phone # Email Authorized ,agent Project Location (County): Street Address/State Road/Lot #(s) Subdivision ! l City Affected ❑CW aEW ❑PTA ES ❑PTS Adj. Wtr. Body: (nat/man/unk) AEC(s): {❑ OEA ❑ IHA ❑ UW ❑ SPIMA ❑ PWS Closest Maj. Wtr. Body ORW: yes/nb PNA: yes/no C' Type of Project/ Activity (Scale! Srr relin<«ren Access Length_ -- Pier (dock)length Fixed Platform(s) I i j i Floating Platform(s) —4— Total Platform area :__ Groin length/fl z� — -— —� Bulkhead/ Riprap length Avg distance offshore --— Breakwater/Sill — �,�� —.r I -- — f, Max distance/length Basin, channel Cubicyards Boat ramp r Boathouse/ Boatlift Beach Bulldozinga�� Other 1- 1/ Z — SAV observed: yes / no .�� j .-}t i� _ t e (� _ �T_ Moratorium: n/a yes no �— Site Photos: yes no— RinarianWaiverAttached: ves no A building permit/zoning permit may be required byi _ Permit Conditions ❑TAR/PAM/NEUSE/BUFFER(circle one) ❑ See note on back regarding River Basin rules ❑ See additional notes/conditions on back I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. i Agent or Applicant PRINTED Name Permit Officer's Signature **Please read compliance statement on backof permit** lli�� Application Fee(s) Check R/Money Order Issuing Date Expiration Date ❑CAMA ❑ DREDGE & FILL GENERAL PERMIT ❑ New ❑ Modification ❑ Complete Reissue ❑ Partial Reissue N9 87329 A B C D Previous permit Date previous permit issued As authorized by the State of North Carolina, Department of Environmental Quality and the Coastal Resources Commission in an area of environmental concern pursuant to: 15A NCAC ❑ Rules attached. ❑ General Permit Rules available at the following link: w deq_nc.gov/CAMArules Applicant Name Address City State Phone # (_ ) Email ZIP Authorized Agent Project Location (County): Street ddlress(State Road/Lot #(s) Subdivision i 1 City / ZIP r Affected 1-1 CW n EW ❑ PTA ❑ ES ❑ PTS Adj. Wtr. Body (naUman/unk) AEC(s): ❑ OEA ❑ IHA ❑ uW ❑ SPIMA ❑ PWS Closest Mal. Wtr. Body ORW: yes/no PNA: yes/no Type of Project/ Activity (Scale: ■®� . .� ■I.....CC'■.■■.�CC■■�� .■E SEEN ■■E . ■�■.� N. ■■. A building permit/zoning permit may be required by: Permit Conditions ❑ TAR/PAM/NEUSE/BUFFER (circle one) See note on back regarding River Basin rules See additional notes/conditions on back I AM AWARE OF STATUTES, CRC RULES AND CONDITIONS THAT APPLY TO THIS PROJECT AND REVIEWED COMPLIANCE STATEMENT. (Please Initial) i Agent or Applicant PRINTED Name _/ i Permit Officer's PRINTED Name Signature -'Please read compliance statement on back of permit•!!• . III �J Application Feels) Check N/Money Order Sign ure '�6 AQ Issuing Date Expiration Date AGENT AUTHORIZATION FOR CAMA PERMIT APPLICATION Name of Property Owner Requesting Permit: -! P- V L.�-eo Mailing Address: Phone Number: Email Address: �3- � tee. � ��:-� , �� • � : 2 Z � � Gi 1� 22 uz`1 I certify that I have authorized M v o Y�' "C k-' to act on my behalf, for the purpose of applying for and obtaining all CAMA permits necessary for the following proposed development: Q oc Y, at my property located at ) _� `f P,3 ri: O D " I +-<= in e- 4-2- -z -t= It County. I furthermore certify that 1 am authorized to grant, and do in fact grant permission to Division of Coastal Management staff, the Local Permit Officer and their agents to enter on the aforementioned lands in connection with evaluating information related to this permit application. Property Owner Information: Signature ki P 1'4- L e_ o rv-L_._ Print or Type Name 0 Title i -z Date RECEIVED This certification is valid through 1 / APR 1 g NZZ DCWMHD CITY ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property a4aoant to � t QI. IZ L--e r v '1 — 's property Dated at T i are / O Party Owner) (Address, Lo Block, Road, e� on NC. eNaterbody) (CitylTown andlor County) The applicant has described to me, as shown below, the development proposed at the above lion_ I have no objection to this proposal. DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (1nclividuaf proposing development must flit In description below or attach a SHO drawing) cy C IL r n w 1 VJ rJ 1 SS C,k qC1 C is ed — _ WAIVER SECTION. I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be Set ba(* a minimum distance of 15' from my area of riparian access unless waived by me. Of you wish to waive the setback, you must initial the appropriate blank below.) \\ i do wish to waive the 1& setback requirement. I do not wish to waive the 16 setback requirement_ (Property Owner Information) (Adjacent Property Owner Information) e T lZ Print or Type Name S� �Z CV' ej , jMing Address y-1�41�+� hl .0 . 2 "7 (-03 Telephone Number 12-?2�--2-1 Dace �mr tl_ �a r�5 /off T ,for;4 � Number - Date ?[`CV—...?\P (Revised UA APR I 2 22 DCM-MHD CITY 4 m DCM-MHD ADJACENT RIPARIAN PROPERTY OWNER STATEMENT I hereby certify that I own property adjacent to I D` /, epo n Q p me of Property owner) property located at 7 1 (Address, Lo Block, Road, etc. on Cf4,y-4 1 in ��b�� } c N.C. (Waterbody) (CitylTown and/or County) The applicant has described to me, as shown below, the development proposed at the above location. V 1 have no objection to this proposal. r :.. . . 1. . •0- DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT (lndtvidual proposing development must fill In description below or attach a site drawing) DJ C k C=X r a") (' I L'C5 ) -i of `I I `+ < h C 4j WAIVER SECTION I understand that a pier, dock, mooring pilings, breakwater, boathouse, lift, or groin must be set back a minimum distance of 15' from my area of riparian access unless waived by me. (If you wish to waive the setback, you must initial the appropriate blank below.) ,y ` ` I do wish to waive the 15' setback requirement. I do not wish to waive the 15' setback requirement. (Property Owner information) Vn'Ze Print or Type Name ailing Address i" ' Al ., N .c . 2 7 C/StaafeZip 1�J -- qZ2— 14 j Telephone Number )2-Z�-z) Date (Ad'acent Property Owner Information) j Si e \J-w ill S Prin or Type ame W7tt'qq�� Addre .f?, a, hc-rol)na City/State2ip Telephone Number �3".2—JN'Jq^ ism Date / I t` zAPR Is NT, l (Revised 61t2012) DCM-MNI) I-- - - - - - -- ----4 J 9 3/9 RECE APR IS DCM-MH