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Environmental Information Form <br /> Part B <br /> DATE: !j _ �U -- 7 <br /> (To be Completed By Applicant ) <br /> NOTE: In completing this form, use additional sheets if necessary. <br /> Answer all questions to the best of your ability. If a 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 Lo e f2 A I ti►mac- Z O k 1NJ S o m <br /> Address_ 7Z6 L 0AJ TleIf 6- <br /> Cit <br /> City - ' C A L O <br /> State/Zip S 2 0 <br /> Phone <br /> A. PROJECT DESCRIPTION <br /> 1 . Type of application: Q use Permit, Major Subdivision, <br /> Q Zone Reclassification, Minor Subdivision, Q Site Approval, <br /> Q Zone variance, Q Other: <br /> 2 . Project location: <br /> Describe the project; i .e. , request being made and nature of use . <br /> Identify specific project components : '7-0 DIVIDE J10 ON(2 4 <br /> A/ ° d pq�Ccip- L 0 C-y o--jrp <br /> A14 PA P2 C�L 2 A A.,,Ojete 1 ?a ,�r <br /> '7ff, S Ae-'e-45 <br /> 3 . Total acreage of project: Q # ofsting parcels: I <br /> Assessor Parcel # (s ) : O -- c�O -- /ex' <br /> 4 . If there is an existing EIR assessing any aspect of your project <br /> site , provide title and date: _ K/ A <br /> 5 . Other permits and approvals (County, Regional, State and Federal ) <br /> required for this project: <br /> PERMIT AGENCY <br /> Minor Subdivision - 7 - ( 6/86) <br />