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Environmental Information <br /> 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 PROPERTY OWNER AGENT OF OWNER <br /> Name /n.404,00 �' Ly <br /> Address 323 City <br /> — -- --- — <br /> State/Zip 7--ora <br /> Phone3GB — GG/8 <br /> TYPE OF APPLICATION_PROJECT <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT N14 AGENCY <br /> -1- ( 9/85 ) <br /> flan-44 (12/85) <br />