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Complete Mail or email to: Kristie Prahl <br />MN Interagency Fire Center <br />402 SE llth Street <br />� Grand Rapids, Minnesota 55744 (218) 327-4572 <br />kristie.prahl(�a,state.mn.us <br />� POSTMARKED NO LATER THAN ............... JUNE 1, 2012 F <br />Fire Department: <br />��b G �T L,4(�F.� �>�(� �El�% <br />Off1C1aI FD Mailing Address: <br />�'�3� �au��Y I��A� f 1 <br />ity, State, Zi <br />E� r�r L�14�� ���U � �� <br />�—.� <br />1. Population directly benefiting from the project: <br />2. Fire Department's protection area (square miles): <br />Name & Title of pers n filling out form: <br />R��{,� � �����.���� s��r��v <br />5 <br />Telephone: Day: �. ��f �,��- �j%,�3r <br />Night: � i�-��6 �'�� r,�.% <br />Cell: � / �' ,�����',� <br />Fire Hall: � � �'_ JC�,�' ��p � <br />FD e-mail: ��q�_��' �E�_�,a�qV "�`�'�,��°�, <br />� .� � <br />17� <br />(excluding mutual aid area) <br />3. Number of fire incidents for the previous year: wildland � structural „�� other� <br />4. Fill in the estimated total cost of the project(s) with the dollar amount. <br />� <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />Wildland Personal Protective Equipment � �$�{„�b, b� <br />Excess Property Equipment Conversion � �$ <br />Wildland equipment � $ <br />Foam unit � $ <br />Slip-on-unit $ <br />Pumps � $ <br />Dry Hydrant or water storage system � $ <br />Other miscellaneous projects (please describe) <br />Hose, nozzles, water movement items <br />Radios/pagers <br />Breathing apparatus <br />Structural Turnout Gear <br />Cascade system <br />Structural Equipment (be specific) <br />/ <br />Fire Department Chief s Signature:.����o ,e�/�t^,� <br />OFFICE USE ONLY: <br />GRANT APPROVED UP TO $ ��,L�T <br />APPROVAL/DATE: ��-��;,'L <br />Date: ✓� p�,� �� <br />� . � . 1 ' ..�L� /f / �' � i!4► <br />CONTRACT NUMBER <br />odified Project: - ApprovaUdate: <br />Exhibit A <br />