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/: <br />,. <br />Marion County <br />- OREGON <br />FAX (503) 588-5495 <br />Salem, Oregon <br />T O: Fax Number <br />~ `~D-'~70/ <br />Company Name <br />Attenrion <br />F r o m: Sender Name <br />r <br />Budget/Project Number <br />(For CouMy Use Only) <br />Number of pages (inciuding cover): ~ <br />if transmission is interrupted or of poor quality, please notify us immediately at (503) 588-5165. <br />FORM 11-PS28 White Copy - Fiscal Senrices Canary Copy - Customer <br />Rev SV92 <br />Date v_~ /~< <br />~ <br />~~~ ~~~~ <br />Department ~'Q <br />Telephone Number ~~~~ ~~~~ <br />