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dgnar nt has 30 days from date of T.H.P.No. I -ipt of a completed application in which I make its recommendations This time Notification No. Received period does not begin until the department receives the appropriate fee (see attached STATE OF CALIFORNIA I schedule). THE RESOURCES AGENCY DEPARTMENT OF FISH AND GAME NOTIFICATION OF REMOVAL OF MATERIALS AND/OR ALTERATION OF LAKE, RIVER, OR STREAMBED BOTTOM, OR MARGIN APPLICANT Pursuant to Sections 1601-1607 of the California Fish and Game Code I of Name of Applicant Mailing Address presenting Name and address of Individual,Agency.Company,etc owning Property or long work. Hereby notify the California Department of Fish and Game of operations to be carried out by or for me ,m to on or affecting Starting Date Ending Date of County, tributary to Name of Stream,River,or Lake Mapr water Body Located Distance and Direction to Landmarks 2tion Township Range USGS Map Co. Assessor's Parcel No. Dperty owners name and address (if different from applicant) is responsible for operations at the site. Name of Person to Be Contacted at Site During Operations /she can be reached at Mailing Address Telephone n. Description of operation 1. The nature of said operations will be as follows: Check all squares which apply. Soil,sand,gravel,and/or boulder removal or displacement ❑ Timber harvesting or any related activity required for harvesting timber Water diversion or impoundment ❑ Temporary,recreational or irrigation dam ❑ Mining—other than aggregate removal ❑ Fill or spoil in bed,bank,or channel Road or bridge construction ❑ Other—Describe below Levee or channel construction 2. Type of material removed,displaced or added ❑ Soil ❑ Sand ❑ Gravel ❑ Boulders Volume Equipment to be used in the described site 4. Use of water(i.e.,domestic, irrigation,gravel, washing,etc.) Quantity Describe type and density of vegetation to be affected,and estimate area involved. What actions are proposed to protect fish and wildlife resources and/or mitigate for project impacts? Does project have a local or state lead agency or require other permits? ❑ Yes ❑ No ,. If 7a answer is yes,please attach or identify any available environmental document 7c. For state-designated wild and scenic rivers,a determination of the project's consistency with the California Wild and Scenic Rivers Act must be made by the Secretary for Resources. Until the Secretary determines theproject is consistent with the Act, the Department cannot issue a valid agreement A tentative agreement will be issued, conditioned upon a finding of consistency by the Resources Secretary. 7d. THIS AGREEMENT IS NOT INTENDED AS AN APPROVAL OF A PROJECT OR OF SPECIFIC PROJECT FEATURES BY THE DEPARTMENT OF FISH AND GAME. INDEPENDENT REVIEW AND RECOMMENDATIONS WILL BE PROVIDED BY THE DEPARTMENT AS APPROPRIATE ON THOSE PROJECTS WHERE LOCAL, STATE, OR FEDERAL PERMITS OR OTHER ENVIRONMENTAL REPORTS ARE REQUIRED. $riefly describe proposed construction methods. Attach diagram or sketch of the location of your operation to clearly indicate the stream other water and access and distance from named public road. Indicate locked gates with an 'A". Show existing features with a solid line( )and proposed features with a broken line(–––––––).Show compass direction. Attach larger scale map if necessary. Project Cost $ _ CARBON NEEDED Signature of Applicant Date 23 tRrr. I I/" tv 83409