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ADJUDICATORY HEARING REQUEST CHECKLIST AND TRACKING FORM I. Permit Decision or Other Department Decision Being Appealed Issuance Date of Decision Document Document Number if any II. Name of Person Requesting Hearing Name of Attorney if applicable Address Telephone No* If you are the applicant or permittee please include the following information with your hearing request A. B. C. D. E* F* G* H. The date you received the permit decision or other decision which you are appealing A copy of the...
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