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a <br /> Environmental Information <br /> 4 � <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 xlnt za- E&4 . /&e" <br /> Address 2/O At zVy,'/lE� <br /> City S <br /> State/Zip /A <br /> Phone <br /> TYPE OF APPLICATION <br /> PROJECT ?O <br /> PA,2G�L 4 /. 26 Ae PA Ag?4,--�L <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT AGENCY <br /> A/p. <br /> -1- ( 9/85 ) <br /> Plan-44 (12/85) <br />