Landowner Information Name of Landowner: Current Address: City: State: ZIP Code: Phone: Fax: E-mail: L&I Regions Where Ownership is Located (Please supply Landowner Contact Information for all regions that apply): Region 1 Region 2 (Whatcom, Skagit, Snohomish, San (King county) - Landowner Contact: Juan, and Island counties) - Landowner Contact: Name: Name: Phone: Phone: Email: Email: Region 3 Region 4 (Clallam, Jefferson, Kitsap and (Grays Harbor, Mason, Thurston, Pierce counties) - Landowner Contact: Lewis, Pacific, Wahkiakum, Cowlitz, Clark, Name: Skamania, and Klickitat counties) - Landowner Phone: Contact: Email: Name: Phone: Email: Region 5 Region 6 (Okanogan, Chelan, Douglas, (Ferry, Stevens, Pend Oreille, Kittitas, Grant, Adams, Franklin, Walla Walla, Lincoln, Spokane, Whitman, Garfield, and Asotin Columbia, Benton, and Yakima counties) counties) Landowner Contact: – – Landowner Contact: Name: Name: Phone: Phone: Email: Email: ___________________________________ _________________________ _________________ Individual’s Name Title Date Please mail, fax, or e-mail completed form to: Logger Safety Initiative Program Office, PO BOX 44608, Olympia, WA 98504-4608 or
Landowner Information Name of Landowner: Current Address: City: State: ZIP Code: Phone: Fax: E-mail: L&I Regions Where Ownership is Located (Please supply Landowner Contact Information for all regions that apply): Region 1 (Whatcom, Skagit, Snohomish, San Juan, and Island counties) - Landowner Contact: Name: Phone: Email: Region 2 (King county) - Landowner Contact: Name: Phone: Email: Region 3 (Clallam, Jefferson, Kitsap and Pierce counties) - Landowner Contact: Name: Phone: Email: Region 4 (Grays Harbor, Mason, Thurston, Lewis, Pacific, Wahkiakum, Cowlitz, Clark, Skamania, and Klickitat counties) - Landowner Contact: Name: Phone: Email: Region 5 (Okanogan, Chelan, Douglas, Kittitas, Grant, Adams, Franklin, Walla Walla, Columbia, Benton, and Yakima counties) – Landowner Contact: Name: Phone: Email: Region 6 (Ferry, Stevens, Pend Oreille, Lincoln, Spokane, Whitman, Garfield, and Asotin counties) – Landowner Contact: Name: Phone: Email: ___________________________________ _________________________ _________________ Individual’s Name Title Date Please mail, fax, or e-mail completed form to: Logger Safety Initiative Program Office, PO BOX 44608, Olympia, WA 98504-4608 or