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Environmental Information Form <br /> Part B <br /> DATE: July 27 , 1990 <br /> (To be Completed By Applicant ) <br /> NOTE : In completing this form, use additional sheets if necessary. <br /> Answer all questions to the best of your ability. If a question <br /> is not applicable to your project, write NA (not applicable ) . <br /> Please do not leave blanks . Incomplete forms cannot be accepted. <br /> PERSON COMPLETING FORM PROPERTY OWNER X AGENT OF OWNER <br /> Name Kieldsen-Sinnock $ Associates , Inc <br /> Address P. 0. Box 844 <br /> City Stockton <br /> State/Zip California 95201-0844 <br /> Phone 209 946-0268 <br /> A. PROJECT DESCRIPTION <br /> 1. Type of application: Q Use Permit, Q Major Subdivision, <br /> Zone Reclassification, ❑ Minor Subdivision, E] Site Approval , <br /> Q Zone variance, Q Other: Use Permit <br /> 2 . Project location: 5790 West State Highway 12 <br /> Describe the project, i .e. , request being made and nature of use . <br /> Identify specific project components : Food Mart and Gas Station <br /> 3 . Total acreage of project: 3 . 00 # of existing parcels :—1 <br /> Assessor Parcel # (s ) : 055-160-20 <br /> 4 . If there is an existing EIR assessing any aspect of your project <br /> site , provide title and date: None <br /> 5 . Other permits and approvals (County, Regional, State and Federal ) <br /> required for this project: <br /> PERMIT AGENCY <br /> Encroachment Permit CalTrans <br /> Septic Tank/Well Permit Health Department <br /> Site Approval Application - 5 - (6/86 ) <br />