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For Staff Use Only <br /> File No . <br /> Date Filed <br /> APPLICATION FORM PART B: <br /> ENVIRONMENTAL INFORMATION <br /> (To be Filled Out By Applicant ) <br /> NOTE : In completing this form, use additional sheets if necessary. <br /> Answer all questions to the best of your ability. If 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 PROPER'T'Y OWNERAGENT OF OWNER <br /> Name Tior. u 0 <br /> Address e <br /> City &CY <br /> State/Zip <br /> Phone <br /> TYPE OF APPLICATION f/VIP A 6y. <br /> PROJ ECT <br /> m a m b eoL -of a ,riL <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT AGENCY <br /> . <br /> &A 0.0 S w. 7' <br /> A'1 i <br /> -1- ( 9/85) <br />