1.Contact information for the person or agency requesting the Amendment:

(1a)Name:
(1b)Street address:
(1c)Street address 2:
(1d)City:
(1e)State/Province:
(1f)Zip/Postal code:
(1g)E-mail:

2.Select the Type of Amendment: Text Area-Wide Map UGA/USA Combined

3. Please describe the proposed Amendment:

The following site specific information is required for proposed Map, UGA or USA Amendments.

4. Please describe the general location of the proposed Amendment:

5. Provide the tax parcel number(s), owners name(s) and mailing address(es) for all the properties included in the proposed Amendment:

(5a)

(5b)

(5c)