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Permit Number C.S. S.R. Area <br />Maintenance Superintendent <br />PERMIT HOLDER <br />Representative’s Name _____________________________________PHONE <br />Contractor <br />DATE reviewed <br />DATE Started DATE Completed <br />DATE PERMIT HOLDER contacted State’s representative before beginning work <br />NAME OF STATE REPRESENTATIVE <br />Remarks <br />DATE paving began ENDED <br />Remarks <br />BUILT according to the permit <br />LOCATION PER PERMIT <br />Remarks <br />EVALUATE THE QUALITY OF WORK <br />Remarks <br />*NOT BUILT according to the permit <br />Remarks <br />Field Review and remarks by: Date: <br />PLEASE RETURN TO REGIONAL PLANNING OFFICE WHEN COMPLETE. <br />***Please add any comments or attachments needed for permanent documentation of this approach. <br />***If the approach is not completed, please list the dates the PERMIT HOLDER was contacted, brief <br />description of conversation, and pictures of approach. <br />ACP 61716 SR-903 MP 3.45 R Page 1 of 1 Exhibit F <br />COPY