WA ST Dept of Fish and Wildlife 3/24/2017

Washington Department of Fish and Wildlife Mailing Address: 600 Capitol Way N•Olympia,WA 98501-1091 Main Office Location: Natural Resources Building•1111 Washington Street SE*Olympia,WA ',,1� FlS9•r Sensitive Fish and Wildlife Information Release Agreement 7-inii EMI Organization Name: C ' J ©� E t" '►ie T� Authorized Representative: It 4.t01 Zit/ Sfiep/v ivo a l� Phone Number yas �.?—g2 3 / Technical Contact(s): tat) IA 4-1-.7(( I toe i4,1 '•'1✓l4- 2.--ti-A(11-•"" Q�'t`'x 9fw ✓4/ Mailing Address: aq 3 tJ W 4 Ytv,P 71-u-f , ju r`7`-P -A / f --4+ 144 '7S-0201 Description of information that you are requesting: 'rr - ;o - Aq't,i7 l of . l,t`r'S 4/_t `ILA Cj /4 -PJr --w1A ! Ca- 7 n 0 t 0 M t`s (Du" -/ +r v�/w e" t 6 �vk i" ,4-y c- f aw-ell Gl L-el U✓l:w Pt ✓Oc cJ TtI G-✓>md I, The Authorized Representative of the said organization, agree to the terms and conditions on the reverse side. I am one of the following parties that are eligible to receive Sensitive Fish and Wildlife Information: Government agency; Tribe;I'm affiliated with an accredited college or university; The owner,lessee, or right-of-way oreasement holder of private land to which the data pertain or who initially provided the data;Public utilities;Agent of the above parties (e.g., consultants, realtors, etc). Authorized Representative Washington Department of Fish and Wildlife Title Ma ty! Title PHS Data Release Manager Name ' t- , ' ;o,it i. Name Lori Guggenmos Signature 'riff, ,1 I'A 4.4 Signature t,c) :' Date1 Date 4110/ .o/7 Please return the signed Sensitive Fish and Wildlife Information Release Agreement form to Washington Department of Fish and Wildlife,Priority Habitats and Species,600 Capitol Way North,Olympia WA 98501-1091. For questions about the form or to address spe , I needs for information distribution not covered in the agreement call(360)902-2543 or e-mail phsprodu^ n, ti'�v. ' A AP VEDA t0 F Le June 2011 KW Release Agreement—Page 2 of 2 "24.• afqr,.LfS,City AttOtnty