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79-201g 1. Provide a complete copy of the Certificate of Completion of Dam and all attachments from the Division of Water Resources. 2. Provide the legal description(s) of the real property owned by you which is contiguous to and a part of the same tract of land upon which the dam or reservoir has been constructed. VERIFICATION I, , do solemnly swear or affirm that the information set forth herein is true and correct, to the best of my knowledge and belief.

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