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Rev.6/26//2001 <br /> Page 5 of 5 <br /> V <br /> Respondent Information: II <br /> Name: 3o kA A - aJ, Pg SU\v Y 0. O <br /> Title: 0%0 tee.r <br /> 6. <br /> Firm: <br /> Property Address: if 1 611 1; -M <br /> 6. co, q <br /> Mailing Address(if different): <br /> 6' 'n Y2 r • C(Adrolccc (zd <br /> <<--k �-.- ,-s—q 6 � <br /> Property Assessors Parcel Number: <br /> ` Phone: <br /> ` Respondent Relationship to Site: Ownerj,--`� Occupant Renter <br /> Type of Property: Commercial Industrial Residential <br /> Preparer represents that to the best of the Preparer's knowledge the above statements and facts are <br /> true and correct and to the best of the Preparer's actual knowledge no material facts have been <br /> suppressed or misstated. <br /> User's Signature Date <br /> Preparer's Signature n Date <br /> v-�'-a�t . 0 `t- <br /> s ondentt's Signature <br /> Date <br /> _ <br /> 6. <br /> P:\3916 Fast Main Street Development (Grupe)\3916 E Main Street Development Phase I\Correspondence\Letters\Phase I <br /> Questionnaire(-06).doc <br /> r n <br /> Initials`q —,P .2O/'j// <br /> r C <br />