Mar 2011 EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • June 15th, 2021
OWNER (name, address, phone number-include day/night/cell/fax) DUNS: EIN/SSN: PAYMENT ADDRESS:[ ] Same as above, or _______________________________________ ________________________________________ INCIDENT NAME: INCIDENT NUMBER: RESOURCE ORDER NUMBER: JOB CODE (P#) AND OVERRIDE:
EMERGENCY FACILITIES & LAND USE AGREEMENT rev. 03/2020Emergency Facilities & Land Use Agreement • February 9th, 2024
INCIDENT AGENCY (name, address, phone number) Page 1 of 3 AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENT AGREEMENT NUMBER:
ContractEmergency Facilities & Land Use Agreement • April 27th, 2016
EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • July 13th, 2020
INCIDENT AGENCY (name, address, phone number) AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER: _ _ EFFECTIVE DATESa. beginning: b. ending: OWNER (name, address, phone number-include day/night/cell) POINT OF CONTACT (if applicable):EMAIL:PAYMENT ADDRESS: Same as above, or DUNS:REGISTERED IN SAM.GOV: Yes or No, Vendor Code Information Worksheet attachedEIN/SSN (only if not in SAM):County: State: Township: Range: Section: INCIDENT NAME: INCIDENT NUMBER: RESOURCE ORDER NUMBER: S- MODIFICATION No/DATE: MODIFICATION CO Initials: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES):SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED HUBZONE SERVICE DISABLED VETERAN PUBLIC ENTITY GOVERNMENT OTHER The owner of the property described herein, or the duly appointed representative of the owner, agrees to furnish the land/facilities for use as . DESCRIPTION OF LAND/FACILITIES: Address or specific location. If street or highway address is unavailable, use
EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • July 13th, 2020
INCIDENT AGENCY (name, address, phone number) AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER: _ _ EFFECTIVE DATESa. beginning: b. ending: OWNER (name, address, phone number-include day/night/cell) POINT OF CONTACT (if applicable):EMAIL:PAYMENT ADDRESS: Same as above, or DUNS:REGISTERED IN SAM.GOV: Yes or No, Vendor Code Information Worksheet attachedEIN/SSN (only if not in SAM):County: State: Township: Range: Section: INCIDENT NAME: INCIDENT NUMBER: RESOURCE ORDER NUMBER: S- MODIFICATION No/DATE: MODIFICATION CO Initials: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES):SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED HUBZONE SERVICE DISABLED VETERAN PUBLIC ENTITY GOVERNMENT OTHER The owner of the property described herein, or the duly appointed representative of the owner, agrees to furnish the land/facilities for use as . DESCRIPTION OF LAND/FACILITIES: Address or specific location. If street or highway address is unavailable, use
EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • December 16th, 2020
INCIDENT AGENCY (name, address, phone number) Page of AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENT AGREEMENT NUMBER
IDAHO DEPARTMENT OF LANDSEmergency Facilities & Land Use Agreement • April 27th, 2016
Fill in the following drawing showing the land/facilities under agreement. Include buildings, roads, paved areas, utility lines, fences, ditches, landscaping and any other physical features which help describe the area.
ContractEmergency Facilities & Land Use Agreement • May 20th, 2013
INCIDENT AGENCY (name, address, phone number) Page of AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER EFFECTIVE DATESa. beginning b. ending OWNER (name, address, phone number-include day/night/cell/fax) DUNS:EIN/SSN:PAYMENT ADDRESS:[ ] Same as above, or _ INCIDENT NAME: INCIDENT NUMBER:RESOURCE ORDER NUMBER: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES) SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED The owner of the property described herein, or the duly appointed representative of the owner, agrees to furnish the land/facilities for use as . DESCRIPTION OF LAND/FACILITIES: Address or specific location. If street or highway address is unavailable, use distance from nearest city, crossroads, or other significant landmark. The local description of how to get to the land/facilities is also acceptable. Borough: State: Private: ORDINARY WEAR AND TEAR: Ordinary wear and tear is based on the customary use of the land/fa
March 2015 EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • September 17th, 2020
OWNER (name, address, phone number-include day/night/cell/fax) DUNS: EIN/SSN: PAYMENT ADDRESS:[ ] Same as above, or _______________________________________ ________________________________________ INCIDENT NAME: INCIDENT NUMBER: RESOURCE ORDER NUMBER: JOB CODE (P#) AND OVERRIDE:
June 2012 EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • July 7th, 2012
INCIDENT AGENCY (name, address, phone number) Page 1 ofAGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER EFFECTIVE DATESa. beginning: b. ending: OWNER (name, address, phone number-include day/night/cell/fax) INCIDENT NAME: DUNS: INCIDENT NUMBER: EIN/SSN: See attached vendor code worksheet RESOURCE ORDER NUMBER: PAYMENT ADDRESS:[x ] Same as above, or JOB CODE (P No.) AND OVERRIDE: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES)□ SMALL BUSINESS □LARGE BUSINESS □SMALL DISADVANTAGED OWNED □WOMEN OWNED □HUBZONE □SERVICE DISABLED VETERAN The owner of the property described herein, or the duly appointed representative of the owner, agrees to furnish the land/facilities for use as DESCRIPTION OF LAND/FACILITIES: Address or specific location. If street or highway address is unavailable, use distance from nearest city, crossroads, or other significant landmark. The local description of how to get to the land/facilities is also acceptable. County: State:
ContractEmergency Facilities & Land Use Agreement • May 20th, 2013
INCIDENT AGENCY (name, address, phone number) Page of AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER EFFECTIVE DATESa. beginning b. ending OWNER (name, address, phone number-include day/night/cell/fax) DUNS:EIN/SSN:PAYMENT ADDRESS:[ ] Same as above, or _ INCIDENT NAME: INCIDENT NUMBER:RESOURCE ORDER NUMBER: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES) SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED The owner of the property described herein, or the duly appointed representative of the owner, agrees to furnish the land/facilities for use as . DESCRIPTION OF LAND/FACILITIES: Address or specific location. If street or highway address is unavailable, use distance from nearest city, crossroads, or other significant landmark. The local description of how to get to the land/facilities is also acceptable. Borough: State: Private: ORDINARY WEAR AND TEAR: Ordinary wear and tear is based on the customary use of the land/faci
March 2015 EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • March 10th, 2015
INCIDENT AGENCY (name, address, phone number) Page of AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER EFFECTIVE DATESa. beginning b. ending OWNER (name, address, phone number-include day/night/cell/fax) DUNS:EIN/SSN:PAYMENT ADDRESS:[ ] Same as above, or INCIDENT NAME: INCIDENT NUMBER:RESOURCE ORDER NUMBER: JOB CODE (P#) AND OVERRIDE: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES)SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED HUBZONE SERVICE DISABLED VETERAN PUBLIC ENTITY(Pursuant to FAR 31.6 & OMB Cir.A-87) The owner of the property described herein, or the duly appointed representative of the owner, agrees to furnish the land/facilities for use as _.DESCRIPTION OF LAND/FACILITIES: Address or specific location. If street or highway address is unavailable, use distance from nearest city, crossroads, or other significant landmark. The local description of how to get to the land/facilities is also acceptable. County: State: T
May 2015 EMERGENCY FACILITIES & LAND USE AGREEMENTEmergency Facilities & Land Use Agreement • November 17th, 2016
INCIDENT AGENCY (name, address, phone number)San Bernardino NF602 S. Tippecanoe Ave. San Bernardino, CA 92408 Page 1_ of _7 AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBERAG-9A14-P-16-5005 scolliercrisp@fs.fed.us (909)929-7052 EFFECTIVE DATESAugust 8, 2016 b. End of Incident OWNER (name, address, phone number-include day/night/cell/fax)City of Redlands/Redland Municipal Airport Quality of Life Department35 Cajon St., Suite 222; Redland, CA 92373Office: (909)798-7655 Ext. 7355 Fax: (909)796-7697DUNS: 094712205EIN/SSN:PAYMENT ADDRESS:[ ] Same as above, or _ INCIDENT NAME: Pilot Fire INCIDENT NUMBER: CA-BDF-10205 RESOURCE ORDER NUMBER: S-1148 JOB CODE (P#) AND OVERRIDE: P5KK6C-0512 TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES)SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED HUBZONE SERVICE DISABLED VETERAN XPUBLIC ENTITY(Pursuant to FAR 31.6 & OMB Cir.A-87) The owner of the property described herein, or the duly appointed repr
EMERGENCY FACILITIES & LAND USE AGREEMENT rev. 02/2018Emergency Facilities & Land Use Agreement • May 18th, 2020
INCIDENT AGENCY (name, address, phone number) Northern California Acquisition Service Area (NCASA) 3644 Avtech ParkwayRedding, CA 96002 Page 1 of 3AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER:129AC720K5003 EFFECTIVE DATESa. beginning: May 1, 2020 b. ending: April 30, 2023 OWNER (name, address, phone number-include day/night/cell)Orland-Haigh Air Field County of Glenn4115 County Road P Orland, CA 95963 INCIDENT NAME: *To be determined at time of use. INCIDENT NUMBER: *To be determined at time of use.RESOURCE ORDER NUMBER: *To be determined at time of use. POINT OF CONTACT (if applicable): Cole Grube EMAIL: cgrube@countyofglenn.net JOB CODE (P#) AND OVERRIDE: *To be determined at time of use. PAYMENT ADDRESS: Same as above, or PO Box 1070, Willows, CA 95988Email: pwfiscal@countyofglenn.net DUNS: 8279643590000REGISTERED IN SAM.GOV: Yes or No, Vendor Code Information Worksheet attached TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES):SMALL BUSINESS L
EMERGENCY FACILITIES & LAND USE AGREEMENT rev. 05/2021Emergency Facilities & Land Use Agreement • May 21st, 2022
INCIDENT AGENCY (name, address, phone number)San Juan National Forest 15 Burnett CourtDurango, CO 81301970-247-4874 Page 1 of 3AGREEMENT NUMBER MUST APPEAR ON ALL PAPERS RELATING TO THIS AGREEMENTAGREEMENT NUMBER:1282X922K4002 EFFECTIVE DATESa. beginning: 05/19/2022 b. ending: End of incident OWNER (name, address, phone number-include day/night/cell)Archuleta, County Of 449 San Juan StPagosa Springs, CO 81147 970-389-0276POINT OF CONTACT (if applicable): Derek Woodman EMAIL: derek.woodman@archuletacounty.org PAYMENT ADDRESS: Same as above, or DUNS: UEI VPPBX1NQ4KH9REGISTERED IN SAM.GOV: Yes or No, Vendor Code Information Worksheet attachedEIN/SSN (only if not in SAM):County: State: Township: Range: Section: INCIDENT NAME: Plumtaw INCIDENT NUMBER: CO-SJF-000203 RESOURCE ORDER NUMBER: S-185 MODIFICATION No/DATE: MODIFICATION CO Initials: TYPE OF CONTRACTOR ("X" APPROPRIATE BOXES):SMALL BUSINESS LARGE BUSINESS SMALL DISADVANTAGED OWNED WOMEN OWNED HUBZONE SERVICE DISABLED VETERAN PUBLIC
