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Complete Mail or email to: Kristie Prahl <br />MN Interagency Fire Center <br />402 SE 111h Street <br />Grand Rapids, Minnesota 55744 (218) 3274572 <br />kristie.prahl6a state.mn.us <br />4 POSTMARKED NO LATER THAN ............... JUNE 19 2010E <br />Fire Dep tment: <br />C c v T LAI <� � <br />N e Title . ers n ili out form: <br />� �l (/ Cy <br />Official FD Mailing Address: <br />Telephone: Day: <br />cotivn/ IN b 1 <br />Night:. / �­?� <br />Cell: <br />Fire Hall: <br />e -mai l: <br />l <br />CWq(lor tate Zip: <br />1. Population directly benefiting from the project: S9loo <br />2. Fire Department's protection area (square miles): <br />(excluding mutual aid area) <br />3. Number of fire incidents for the previous year: wildland --� structural other <br />,-.... Fill in the estimated total cost of the project(s) with the dollar amount. <br />$ 996,D# <br />Wildland Personal Protective Equipment <br />$ <br />Hose, nozzles, water movement items <br />$ <br />Excess Property Equipment Conversion <br />$ <br />Radios /pagers <br />$ <br />Wildland equipment <br />$ <br />Breathing apparatus <br />$ <br />Foam unit <br />$ <br />Structural Turnout Gear <br />$ <br />Slip -on -unit <br />$ <br />Cascade system <br />$ <br />Pumps <br />$ <br />Structural Equipment (be specific) <br />$ <br />Dry Hydrant or water storage system <br />$ <br />$ <br />Other miscellaneous projects (please describe) <br />Fire Department Chiefs Signature: a, �, U) - <br />JA�-NCWK Date: � <br />OFFICE USE ONLY: <br />GRANT APPROVED UP TO $ PRIORITY IS FOR <br />APPROVALMATE: /� /� CONTRACT NUMBER <br />lodified Project: <br />Exhibit A <br />Approval/date: <br />