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Home My WebLink AboutTR-4600Board Of $outhold Town Trustees SOUTHOLD, NEW YORK PERMIT NO. /"J~[~) DATE: ...g_6¥ 23, 1996 Au horiza io Pursuant to the provisions of Chapter 615 of the Laws of the State of New York, 1893; and Chapter 404 of the Laws of the State of New York 1952: and the Southold Town Ordinance en- titled "REGULATING AND THE PLACING OF OBSTRUCTIONS IN AND ON TOWN WATERS AND PUBLIC LANDS and the REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM LANDS UNDER TOWN WATERS;" and in accordance with the Resolution.of The Board adopted at a meeting held on Ma¥..23 ..... 19 9.6, and in consideration of the sum of $ !5~)...0Q paid by J...Dee~zkoski of N.Y. and subject to the Terms and Conditions listed on the reverse side hereof, of Southold Town Trustees authorizes and permits the following: to construct a single family dwelling approx. 75' from wedands. Hay bales must be placed 50' from the northwest property lir~e and no clearing shall take place within that 50'. all in accordance with the detailed specifications as presented in the originating application. IN WITNESS WHEREOF, The said Board of Trustees here- by causes its Corporate Seal to be affixed, and these presents to be subscribed by a majority of the said Board as of this dat,e. Albert $. Krupski. Presiden! John Holzapfel, Vice President Jim King Martin H. Garrell Peter Wenczel BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Town Hall 53095 Main Road P.O. Box 1179 Southold, New York 11971 Telephone (516) ~65-1892 Fax (5161 765-1823 May 23. 1996 James Deerkoski 32 Pegs Lane Riverhead, NY 11901 Re: SCTM ~114-10-2 Dear Mr. Deerkoski: The following action was taken by the Board of Town Trustees during its regular meeting held on May 22, 1996 regarding the above matter: WHEREAS. JAMES DEERKOSKI applied to the Southold Town Trustees for a permit under' the provisions of the Wetland Ordinance of the Town of Southold, application dated April 15, 1996, and, WHEREAS. said application was Conservation Advisory Council recommendations, and referred to the Southold Town for their findings and WHEREAS. a Public Hearing was held by the Town Trustees with respect to said application on May 22, 1996, at which time all interested persons were given an opportunity to be heard, and, WHEREAS. the Board members have personally viewed andare familiar with the premises in question and the surrounding area, and, WHEREAS. the Board has considered all the testimony and documentation submitted concerning this application, and, WHEREAS, the structure complies with the standard set forth in Chapter 37-18 of the Southold Town Code, WHEREAS, the Board has determined that the project as proposed will not affect the health, safety and general welfare of the people of the town, NOW THEREFORE BE IT, RESOLVED, that the Board of Trustees grant a Wetland Permit to construct a single family dwelling approx. 75' from wetlands Haybales must be placed 50' from the north west property line and no clearing shall take place within that 50', and, BE IT FURT~ RESOLYED that this determination should not be considered a determination made for any other Department or 'Agencywhich may also have an application pendinq for the same or similar project. Permit to construct project will expire two years from the date it is signed. Fees must he paid, if applicable, and permit issued within six months of the date of tkis notification. Two inspections are required and the Trustees are to be notified upon completion of said project. FEES: None. Very truly yours, Albert J. Krupski, Jr. President, Board of Trustees AJK/jmd cc: CAC ~elephone (516) 765-1801 Town Hall. 53095 Main Road P.O. Box 1179 Southold, New York 11971 SOUTHOLD TOWN CONSERVATION ADVISORY COUNCIL At the meeting of the Southold Town Conservation Advisory Council held Monday, May 20, 1996, the following recommendation was made: No. 13~8 Moved by Robert Keith, seconded by Allan Connell, it was RESOLVED to recommend to the Southol.d .T. own Board of Trustees APPROVAl WITH CONDITIONS of the Wetland Appllcatmn of JAMES DEERKosKI to buil~t a single family 2-story dwelling with garage. ' 260 Deer Drive, Mattituck The CAC recommends approval jf runoff is contained using hay bales, drywells, etc. and that there be no clearing wlthin 75~ of the wetlan~[s. Vote of Council: Ayes: All Motion carr|ed. A~pe~dix C SHORT ENT ~FORM ~ROOF OF MAILIN~ O~ NOTICE ATTACH CF/~TIPIED M~IL RECEi~ Albert J: Krup~ki. President John Holzapfel. Vice President William G. Albertson Martin H. Garrell Peter Wenczel Town Hall 53095 Main Road P.O. Box 1179 Southold. New York 11971 Telephone (5 t 6~ 765-1892 Fax ~ 516) 765-1823 BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Office Use Only Coastal Erosion Permit Application ~Wettand Permit Application GrandfatherPermit APplication Trustee Lands Permit Application Waiver Received Application: Clerical Review: Completed Application. ~ncomplete~. =EQRAClassifi~ation: { F!rpe I Type II Unlisted Coo~tion:(~at? s'e~nt~ ' ~CAC ReferraI Sent. q/[~/~,, .__~a~e of Inspection:'/ ~ceipt of CAC Lead Agency Determination: Technical Review:(date), ~-Public Hearing:(date)~/~/~ ---Decision: Approved (Y/,~ {date) Application Fee:$ /~)O~ c~/~ Name of Applicant ~f0~ h~w~o~<~ Phone Number:[~) 7~ s~folk cou~t~ Tax ~ap ~mber: lO00 [l~~ tO - Z Proper~y Location: 2~O ~ h~,~.~-,, (provide LILCO Pole ~,1 distance to cross streets, and location) Agent: (If applicable) Address: Phone: ~rd of Trustees Applicatic~ GENERAL DATA Area Zoning: ~O~TI~ 7 Previous use of property: ~C--~;~7, Intended use of property: ~_~i~-C.~_ Prior permits/approvals for site improvements: Agency Date ~ No prior permits/approvals for Has any permit/approval ever been revoked or governmental agency? ~ No__ If yes, provide explanation: site improvements. suspended by a Yes Project Description (use attachments if necessary): 2 hard of Trustees App!icatie~ WETLAN~/TRUSTEE LAlqDS Purpose of the proposed operations: APPLICATION DATA Percent coverage of lot: O % Closest distance between nearest existing structure and upland edge of wetlands: feet ~ }~ V~C~4r~ Closest distance between nearest proposed structure and upland edge of wetlands: ~' feet Does the projec~ No If yes, how much material will be excavated? 800 How much material will be filled? ~ cubic yards Depth of which material will be removed or deposited: ~O feet involve excavation or filling? ~ Yes cubic yards Proposed slope throughout the area of operations: Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal wa~ers of the town that may result by reason os such proposed operations (use attachments if appropriate): ~ - . SEQ~ Appendix A " State E~vironmental Quatty Review - FULL ENVIRONMENTAL ASSESSMENT FORM "' Purpose: The fuji ~AF is desk,ned ~o heJpappJic~n~s ~nd agencies de,ermine, in zn orderly manner, whemer ~ pro~ec or acdon mzy be significant. The %~es~on ~ whether an acdon may be ~i~nific:n[ i~ not a ways easy ~o ~nswer. Frequen~ Iy, there zre ~sfec~ o~ a proiec= ~ha~ zre subiecdve or unmeasureable_ It is zJso' understood that those who demrmM( sianificbnce may have li~de or no formal ~ ~owied~e of ~he ~vironme~ 3r may ~e [echnic~Hy expert in environmen~a ~nalvsis. in ~ddkion. man'/who have knowh .dso.in one far~cul~r zrea m~v no[ ue aware of :he brozder concerns the cuestJon of sigE [fJcance. The full fAF is intended to urovide a m process has been order[y, comprehensive fnr Full EAF Components: The full EAF is corr Par~ 1: Provides'~b:ective data and data it assists a rewewer in ?art 2: :ocuses on identifying the ra guidance as to whether an im large ~mpacc. The form also Part 3: If any irnoacc in Part 2 is id~ .~thod whereby a 2piicants ann agencies can ~e assured that the determination amre, yet flexible to allow introduction of info[marion to fita~roiect or action ~rised of mree parts: nformation about a given projecfand its site. By identifying basic projec: the analysis that takes elate in Pa~s 2 and 3_ ~ge of possible imoac.ts that may occur from a project or action. It provtdes DETERMINATION 0 Identify the Portions of CAF completed f Uoon review ~f the information inf6rmation and considering Doth the ma /eac agency mat: ~ A, The project will nec result nave a stgmhcant re.pact on : SIGNIFICANCE--Type I and Unlisled Actions )r this project: ~ Part I ~ Part 2 ~Part 3 on tins EAF'(Parts 1 and 2 and 3 if appropriate], and any omer suoporting ;~tude.and imoortance of each ~mpact. it is reasonaow aetermir.=d by [ne any large and important impact(s] and therefore. 's one which will not the envtronment, therefore a negative declaration will be preparea. · A Conditioned Negative Declaration is only valid for Ur~ isted Actions 8, Aknough the oroiect couM h~ /e a s~gnificant effect on the environmen: there will no~ be a significant effect for ~his Uni sted Action because the m~tigadon measures described in PART 3 have been required, therefore a CONDITIONED negative declaratloo will be prepared.' C. The pro~ect may result in one or more large and imoortant imoacts that may nave a significant impact on the environmenL therefore a positive declaration wlil be prepared. Name of Action Name of Lead Agency Print or Tx pe Name of Respor~sibh_, Officer m Lead Agency Title of Resoons~bie Officer C Signature 3f Responsible Officer in Leae Agency Signature of Preparer(If different/rom resnons~ble officer} PART 1--PROJECT INFOP:'~ATiON PreC)ared by Project Sponsor NOT[CZ: This document is designed to assist in determining whether the action erouosed may have a significant e on the envfronment. P[ease complete the entire form. :arts A through E. Answers co these ~uesuons will be cons~c ~s fart of' the a uplicadon for auorovai and m~v be sumect to further verification aha gubiic re~/~e,,v. Prow~e any addit informadon.vou ~eiieve will be needed to comoiete Par~ 2 And 3, It is exBected that completion of the full EAF will be deoendent an information currenuv available end will nec im new studies, research or investigauon. [f information reau~Hn~ such additional work s u navaufeie so indicate and sB eac~ instance. BUSINESS TELEPHONE Please Complete Each Question--Indicate N.A. if not applicable A. Sit_e Description Physical setting of overall prelect, both developed and undeveJooeo areas. 1. Present land use: iq, Urban F'llndusr. rial ~Commerciai .~ResidentiaI [suburban) FqForest I-tAgricuiture ~Other 2. Total acreage of project area: ~,~. acres. APPROXIMATE ACREAGE PRESENTLY Meadow or 8rushland [Non-agricultural) . I~" 'acres Forested acres Agricultural (Includes orchards, cropland, aasture, etc.) acres Wetland (Fresh'rater or tidal as per Articles 24. 25 of ECL) acres Water Surf.ace Area a.cres Unve~etated (Rock. earth or fill] acres Roads. buildings and other oared surfaces acres Other [Indicate tree), acres 3. Wha[ ~s predominant soil type(s) on project site? ~. Soil drainage: ~ell drained ~Poorfv drained % o¢ si~e ~Rurai [non-fa AFTER. COMPLETIOh , i.¢0 acre,. ~Moderatelv well drained % or site b. tf an,/ agricultural land is involved, how many acres of soil are classified wid~in sod group ! d~rough 4 of tne ;, Lana ~assltlcauon System? · acres. (See 1 NYCRR 370l. 4. Are there becrac~ outcropomgs an project s te~ ~Yes ~Na a. What ~s de,th ~o bedrock? {in ~eet) -6_ ts pro ec~ subs~nU~liy contiguous co, or :~m a ~uiidi~g, site, or district. Hs~ed on ~he 5(ale or one NaUonz ' Is project 5ubstandaIIy contiguous tea si~e li~ted on ~he Register of NadonaJ Natural Landmarks~ ~Yes ' 8. Wh~t s the.deoth of the water tabte~ ~O (in feet~ 9. ~5 ~ite located over a primary, principal, or sole source aquifer~ ~Yes ~ No 10. Do hunting, fishing or 5heil fishing opportuniues presently'exist [n ~he prelect ~rea¢ ~Ye5 ~o ~1. O~es pro]ec~ site contain any species of o~a~ or animal ii~e that is identified as threatened or endangere~ ~o According ~o ~Yes Identify each species 12. Are there ~ny aniQue or unusual ~and forms on the prelect site? (Le., cliffs, dune~, o~her geological formadon~ ~Yes ~o Describe 13. Is thd Drain, c: sit~?resently used 0y the-community oP neighborhood as an open space or recreation area ,r-~Yes ~o If yes, exPlain- 14. / ' ' Does the presertt site include scemc views known to be imeortan: co the community? DYes ¢,~o , 15. Streams ,vithin ar co¥~tiguous to proiect area: a. Name of Stream and name Df River to which it [5 tributary 16_ Lakes. cones wedand areas within or contiguou~ to proiect area: a. N me 4rr 17. Is the ske serve~ uv exisdn8 public utilities? ~es ~o a) tf Yes. does sufficient c~acitt' exist to allow connection~ ~tes ~o b) tf Yes. will }msrovement~ be necessary ~o 18. Is the site ~ocated in an agricuit~district terrific6 pursuant co Agriculture ~nd Markets L~w. Articie 2S-AA Section 303 an~ 304? ~Yes d9 s the Site loc&re6 tn or of the ECL, and 6 NYCRR 6177 ~Yes ~No . 20. Has the site ever been used :or ~he disposal o¢ solid or hazardous wastes? ~Yes ~o (_ B. Project Description. 'i. Physical dimensions and scale of project (fiji in dimensions as appropriate) a. Total contiguous acreage owned or cot, trolled by projec~ sponsor ~ /~' acres. b. Project acrease to be developed: -/'~ ~'~ acres initially; * ~'~' acres uJdmateJv c. Prolec: acreage to ~emain undeve~ooed ¢ i0 acres. d. Len~[h ~f proiect, in miles: elf aooropr~ate) e. If the project is an expansion, indicate percent of expansion ~FODOSe~ %; ~. Number o~ off-stree~ parkin8 spaces existin8 ; orooosed g- Maximum vemcuJar tr~as ~enerated per hour {unon completion of proiect)~ h, If ¢esident~a~:' Number and ~ype of housin~ On~amii~ Two Family Muit~ote Famdv ImtiaHv Uhim ~e~v _ ~ i. Olmens~ons(in fee~)o~ largest proposed s~ructure ~Of height;~e~ wid~h:~ ~1 length. ]. Linear feet 3f fron~ase alon8 a aubFc thoroush~re proiect will occuav Condominium 3 a. f yes. for what intended ~umose is the site bemg ret[aimed? b. Wil] topsoil be stockoiied for reclamation? ~es c. Will upper subsoil be stockpiled for fcc!ama?ion? j~es f-No 4. ~ow many acres of vegetat]on [trees. shrubs, ground covers)~will be removed from site? '~ acres. 5. Will anv ma~ure forest (over 100 ,.'ears old] or other [ocaH,--importan~ vegetatmn ue removed by this ' ~Yes ~No 6. [f single ~hase project: Antic! pated period of construction 7. If muiti-ohased: a. Total number of phases anticioated b_ A~ticipatea date of commencement phase '[ c. Approx)mate completion date of final Dbase d. Is Dbase I functionally dependent on subsequent ohases? 8. Wiil blas:ing occur during construction? ' t-Wes /~o 9. Number of iobs generated: during construction 10. Numeer oi iobs ei minored b? this ~rolec~ · 11, Will prolecz reau~re relocation of any projects or facilities? (number). monms, [including demoiition/. month veal [including aemolition month year. ,r'lYes after project ~s comolete ~Yes o- If yes. exmam 12. Is surface liquid waste disoosm nvoived? []Yes ~;No a. tf yes. ndicate type of waste (sewage, industrial, etc.) and amount b. Name of water bad'.' into which effluent will be discharged !3. Is subsurface iouid waste disposal involved? []Yes []No Type 14. Will surface area of an existing water bed'. increase or decrease Dy proposal? Exmain 15. ls proiecz or any paruon of project located in a 100 veer flood plain? []Yes []Yes ENo 16 Will the projec: generate solid waste? ffSYes FUND a. If yes, whet'is the amount aer month Eons b. If yes. will an existing solid waste facilitv be used? []Yes c. If yes, give name IDEation d. Will an~ wastes no{ go into a sewage disposal svsmm or nto a sanitary landfill? e. If Yes, explain ENo t7. Will the proiecz involve the.disp°~ai of solid waste? [Yes a. if /es, what is the anticioated-rate of disposal? b. If yes, what is the anticieated site life? . lcears. 18. Wii proiect use herbicides or pesticides? []Yes ~,tqo tons/month. 19. Wii proiect routinely produce odors [more than one hour per day]? m~Yes 20. wii -~roiect oroduce operating noise exceeding the local ambient noise levels? 21. Will prolec~ result in an increase in energy use? ~Yes ~o If yes , indicate typcfs) []Yes 22. If water suopty ~s from weils, indicate eumpmg ca~ac:c¥ gallons minute 23. Tata~ anticipated water usage per day gallons/day. 24. Does proiect involve Local. State or Federal funding? [Yes ~o ~f Yes, explain - 4 25, App~s',t[s City, Town, Ydla~e Go,~d .C C~Yes City, Town. ViIla~e PIannin~ Board E]Yes aND -City, Town ZoninD Board ~es ~No City, County Health Oep~rtmen.t ~Yes Other Local A~enci~s ~Yes ~No Other Regional A~enc~es ~Yes ~No State A~enc~es ~es ~No ' Federal A~encies ~Yes ~No Type Date C, Zoning:and Planning Information 1'. Does proposed action invol';,e a planning-or zonmg decision? F'~Yes ~1~o · If Yes, indicate decision required: [~zoninR amendment filzoning variance ~]suecial use 3ermit [-']subdivision _ ~site C~newirevision or master Dian {~resource management ~lan F~other 2 What is the zoninq ~tassification(s)of the site~ ~-~r'~'l~-~lL ' 3 What is the maximum potential deveiooment of the site if deveiooed as permitted bv the present zomns! .4. 'What is the ~rooosed zonin~ o[ the site? ,~..~'1%~,~1 . 5 What is the maximum ootentiai devetoomen~ of the site if developed as ~ermitted bv the DroDosed zoning? __ ~ 6 Is the proposed action consistent ~wth the recommended uses m adopted local land use ~lans~ ~'es 7. What are the Dredommant land usc(s] ~nd zonm~ classifications wid~in a % mile radius or proposed ~t~on~ 8. Is the pro~oseu action compatible with adioining/surrour~ding lafld uses within a M mile~ ~es 9. I~ d~e proposed action ~ the subdivision of land. how many lots are Droposed~ a. Wha~ is the ~immum lot size proposed? 10. Will proposed action require any authorization(s) for the formatioo of~e~er or water districts~ ~Yes 11. Will the proposed action create a demand for any community provided services (recreation. education. ~olic~ fire protect on)? ~Yes ~No .. n. I~ yes, is existin~ c;~aciW sut~icient to handle proi~:c~ed demand? ~Yes ~No 12. Will ~he proposed action result in U~e ~erlernliDn o~ tra~f C S gnificantlv above present levels? ~Yes - ~c a. I{ yes. is the exi~tin~ f~ad network adenuate to handle the additional traffic? ~Yes D. Informational De[ails avoid lhem C E. Verificnlion I certi[y fllat th~' infornt,ltion I)rc-~wci~,d 4boy,, ~s trtl(, [0 [11~, h~!st oi my ~';;l(~',"¢lt;t)~. ~ . If Ihe ,icllm~ is in lh~, Co~l,d Area..~d yin, .~re a si,il ~ al,~'ncy, cr~l~lllel~' the Coastal Assessment Forl~ beiore proceeding 5 Part 2--PROJECT IMPACTS AND THEIR MAGNITUDE Responsibility of Lead Agency General Information (Read Carefully) · In compJeting me form the reviewer should be guided by the ¢ Jesdon: Have my responses and determinations been reasonable? The reviewer ~s not expected to be an expert environmental analyst. · Identifying that an impact wi[[ be potentia[Iv large (column 2) does not mean that it is also necessarily significant. Any large impact must be evaluated in PART 3 to determine significance, dentifying an impact ir column 2 s~r~D[v ask,~ that it be looked at further. · The Examples provided are to assist the reviewer bv showing types of impacts and wherever possible the threshold of magnitude that would trigger a response in column 2. The examples are generally applicable throughout the State and for most situauons. But. for any specific proiect or site other examples and/or lower thresholds ma~ be appropriate for a Potential Large Impact response, thus reqmring evaluation in Part 3. · The ~mpacts of each project, on each site. n each locality, will vary. Therefore. the examples are illustrative and have been offered as guidance. They do not constitute an exhaustive list of impacts and thresholds to answer each question. · The number of examples per question does not indicate the ~meortance of each question. · in identifying impacts, consider long term. short term and cum[ative effects. Instructions (Read carefullyj a. Answer each of the 19 ouestions in PART 2. Answer Yes if there wilt be any impact. b. MaYbe answers should be considered as Yes answers. c. If answering Yes to a question then check the appropriate box (column 1 or 21 tc indicate the uotentia[ s~ze of the imnact, if im 3act threshold equals or exceeds any example provided check column 2. If in- pact will occur but threshold is lower than example, check column 1. d. If reviewer has doubt about size of the ~rp 3act then consider the imoact as potentially large and proceed to PART 3 e. If a ~otentia[ly large impact checked in column 2 can be mitigated by change(s) in the project to a small to moderate indicates that such a reduction s not possible. This impact, also check (he Yes box n column 3 A No response must be explained in Part 3. IMPACT ON LAND 1 Will the proposed action resuJt in a physical change to the project site? []NO 7~YES Examples that would apply to column 2 · Any construction on slopes of 15% or greater. (15 foot rise per 100 foot of length), or where the general slopes in the project area exceed 10%. · Construction on land where the depth to the water table is less than .3 feet. · Construction ot paved parking area for 1.000 or more vehicIes. · Construction on land where bedrock is exposed or generally within 3 feet of existing ground surface. · Construction that will continue for more than 1 year or involve more than one phase or stage. · Excavation for mining purposes that would "emove more than 1.000 tons of natural material ~i.e., rock or soil) per year_ · Construction or expansion of a sanitary landfill. · Construction in a designated floodway. · Other ~mpacts 2. Will there be an effect to any unique or unusual land forms found on the site? (i.e., cliffs, dunes, geological formations, etc.)E~NO []YES · Specific land forms: 6 I 2 3 Small to Potential Can Impact Be Moderate Large Mitigated By Impact impact Project Change [] [] []Yes ]~No [] [] ~]Yes []No [] [] []Yes []No [] [] []Yes []No ~ [] []Yes []No [] [] []Yes []No [] [] ~]Yes []No [] [] []Yes ~No ~ ~ ~Yes' ~No ~ ~ ~Yes ~No ~ard of Trustees Applicati~ County of Suffolk Staue of New York SWORN TO BEFORE ME THiS EINC SWORN DEPOSES AND Ar~£RMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S) AND THAT ALt. STATemENTS CONTAINED n~EIN ARE COMPLETING THIS APPLICATION, i Pik~EBy AUTHORIZE ThE, ~RUSTEES, THEIR AGENT(S) OR REPRESENTATIVES(S), TO E~T~R ONTO M~PROPEE.i~/ TO INSPECT THE PREMISES iN CONJUNCTION WITH REVIEW OF THIS APPLICATION. JEFFREY F, KAYTJS Nota~ Public, StateOf New York No. 52-4906847 Qualified in Suffoik Count¥ Commiss.~cn F.~pires ,Ma~p~ Albert J. I~r'apski, President John HolzapfeL Vice President Wil~am G. Albe~son Martin H. Ga~etl Peter Wenczel BOARD OF TOWN TRUSTV. ES TOWN OF SOUTHOLD Town Hal 53095 Man Road P.O. Box I179 Sou~ol~ New York 11971 Telephone (516) 765-t892 Fax (516) 765-I823 Office Use Only Coastal Erosion Permit Application --~Wetland Permit Application Grandfather Permit Application Trussee Lands Permit Application Waiver Received Application: Clerical Review: Completed Appli~a~on, r SEQRA ClassifiCation: · Determination: Review:(date) Public ~earing:(date) Decision: Approved (Y/NL (date] Application Fee:S Name of Applicant ~J~O~ ~~~-~ - Phone Number:(~) 7~ Suffolk County Tax Map N~er: 1000 /(q-- lO- ~. Property Locatlon: ~0 ~ ~¢/ ~provi~e ~i~gO ~ole ~, ~ista~ce to cross streets, and location) AgenL: {If applicable) Address: Phone: 0 ~0