STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

NAME OF PERSON(S)FILING PETITION, )

)

Petitioner, )

)

vs. ) Case No. (This will be

) assigned after the

NAME OF PERSON BEING SUED, ) petition is filed)

)

Respondent. )

__________________________________)

PETITION UNDER THE FLORIDA CONSTRUCTION MATERIALS

MINING ACTIVITIES ADMINISTRATIVE RECOVERY ACT

1. The name, address, and telephone number of the Petitioner.

2. The name and address of the Respondent, including the applicable user license holder under Section 552.091(5) and permit holder under Section 552.30, Florida Statutes.

3. The approximate time, date, and place of the use of explosives which is alleged to have resulted in damage to the Petitioner.

4. The name of the county where the alleged damage occurred.

5. A description of the damage caused and the amount sought for recovery. If more than one item is alleged to have been damaged, each item must be individually listed along with the amount sought for recovery related to that individual item.

___________________________________

Petitioner's name or Petitioner's

attorney's name and Bar number

address

telephone number

(Please note that a copy of this petition must be served on the respondent by the petitioner at the time the original petition is filed at the Division of Administrative Hearings)