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° Environmental Information <br /> r: t <br /> c .. <br /> ,Cl POPS <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 uow-e6IGh 5K 17?aLZ _ <br /> Address 323 rr! <br /> City <br /> State/Zip 4SZ¢o <br /> Phone �3GB — GG/8 <br /> TYPE OF APPLICATION- <br /> PROJECT <br /> PPLICATIONPROJECT /V <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT l� AGENCY <br /> -1- ( 9/85 ) <br /> 111ail-44 (12/85) <br />