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E,NVIR.ONMENTAL INFORMATION CIWMB 502(Rev. 9/02) <br /> Page 3 of 4 <br /> GOVERNMENT REQUIREMENTS CON'T <br /> If any permits have been obtained, list permit type and permit number for each(attach additional pages if necessary): <br /> 1. Permit Type: Permit No: <br /> Contact: Phone: Date: <br /> Department: <br /> 2. Permit Type: Permit No: <br /> Contact: Phone: Date: <br /> Department: <br /> Are any additional state or federal permits required for your project? (e.g.,Federal Regulatory Commission,U.S. Forest Service, <br /> Bureau of Land Management, Soil Conservation Service, Department of Water Resources(Division of Dam Safety),Reclamation <br /> Board,Coastal Commission,State Lands Commission,etc.). For each agency from which a permit is required,provide the following <br /> information(attach additional pages if necessary): <br /> L Agency Name: I Permit: <br /> Contact: Phone: Date: <br /> 2. Agency Name: Permit: <br /> Contact: Phone: Date: <br /> Has your agency,or any permitting agency,prepared any environmental documents for your project? <br /> ❑ Yes, Submit a copy of the latest environmental document with this application, including a copy of the notice of determination. <br /> ❑ No, Will any environmental documents be prepared by any permitting agency,other than the CIWMB for your project? <br /> If No,explain: <br /> SCH#: I I Name of Environmental Document: <br /> Note: The final environmental document(including notice of determination) or notice of exemption must be submitted to the Board. <br /> Processing of your Waste Tire Facility Permit cannot proceed until such documents are submitted. <br /> ENVIRONMENTAL SETTING <br /> Describe the current land use of the facility and adjacent properties within 1,000 feet of the facility. If possible, attach photographs of <br /> these areas. Date and label photos. <br /> On-site: <br /> Adjacent Properties: <br />