1. Stream Name (Please write the full name of the stream or river)

3. City or Town (Please write city or town closest to the area of use)

4. Where is the stream being used? If use occurs in multiple locations, please list them all below. (Please be specific so the location can be identified on a map, e.g., 9th Street Bridge, Anytown City Park, Quarter Section-Township-Range, Latitude/Longitude, etc).

5. Have you or your family personally used the stream at this site(s) for recreation since Nov. 28, 1975?