DUST CONTROL APPLICATION

Name: Phone #:

Mailing Address:

Legal Land Description:

Rural Address: (Office Use Only) Maintenance Area:

THE APPLICANT AGREES TO THE FOLLOWING: 1. Application Fees must accompany the Application Form. AN APPLICATION FEE OF $398.00 MUST BE PAID. This fee covers one spring application and one fall application and represents approximately 33% of the cost of purchasing and applying the Dust Control Agent. The FEE for ONE APPLICATION would be half of the fee charged for two applications. 2. The Dust Control Agent to be used is Calcium Chloride. 3. That a 200 metre strip of road in front of the residence or at a location determined by the applicant will be treated with the dust control agent. 4. That the applicant may choose either: PLEASE CHECK: a) spring and fall applications; or Spring Only Fall Only Spring & Fall b) only one of the above. 5. The County does not guarantee the effectiveness of the dust control agent. 6. Dust control agents will not be applied on private or leased roads. 7. Dust control agents will not be applied on roads scheduled for rebuilding or upgrading within one year. 8. The information given on this form is full and complete and is, to the best of my knowledge, a true statement of the facts relating to this application for dust control.

Signature of Applicant Date

OFFICE USE ONLY – DO N O T F I L L - I N P L E A S E

Standard Applications & Fees Over 200 m Applications & Fees SPRING: 200 m $199.00 ______m $______FALL: 200 m $199.00 ______m $______SPRING & FALL: 200 m $398.00 ______m $______

POST-DATED CHEQUE FOR FALL APPLICATIONS – YES

APPROVED:

Director of Infrastructure Services Date

This personal information is being collected under the authority of the Freedom of Information and Protection of Privacy Act, R.S.A., 2000, and will be used for applying Dust Control. It is protected by the privacy provisions of the Freedom of Information and Protection of Privacy Act, Statutes of . If you have any questions about the collection of this personal information, please contact the Director of Infrastructure Services, , 2716 – 1st Avenue, Edson, Alberta, T7E 1N9, (780) 723-4800.