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8.G.d I <br /> ARIZONA DIVISION OF EMERGENCY MANAGEMENT <br /> DESIGNATION OF APPLICANTS AGENT FORM <br /> The intent of this DESIGNATION is to appoint an APPLICANT'S AGENT for the following term:. to <br /> 'For PCA No. I°502.only , ❑For the period of to ❑ Until further notice <br /> Until further notice for HAZMAT incident Q <br /> Applicant Name: <br /> Q <br /> . a <br /> CERTIFICATION <br /> co <br /> ,duly appointed and of <br /> (Authorizing Official's Name). (Title) <br /> to <br /> ,do hereby certify that the information below is true H <br /> (Applicant Name)" E <br /> and correct, based on a resolution passed and approved by the ' <br /> (Governing Body) <br /> U <br /> of on the ' day of , <br /> (Applicant Name) (day) (month) (year) <br /> has been designated as the Applicant Agent <br /> (Name of Designated Applicant Agent) <br /> to act on behalf of Q <br /> (Applicant Name) t <br /> Q• <br /> o> <br /> 03 <br /> (Authorizing Official's Signature) (Title) (Date) <br /> Designated Applicant's Agent L. <br /> Name _ <br /> Title/Official Position • <br /> c <br /> cc <br /> V <br /> Mailing Address �. <br /> a <br /> City,State,Zip <br /> - d <br /> 03 <br /> Daytime Telephone Number Fax a� <br /> (Please include area code end extension if not a direct number) <br /> a) <br /> E-mail Address Pager/Cell a <br /> For ADEM Use Only I x <br /> I Received By: July 2000 Form#AZ PA 2044 <br /> (initials&Date) E <br /> - s <br /> CC <br /> I Packet Pg.89 <br />