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Environmental Information Form <br /> Part B <br /> DATE : <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 /> iN C-5ClorJ <br /> PERSON COMPLETING FORM _PROPERTY OWNER AGENT OF OWNER <br /> Name A,TA GAn1GAi)NARA,i <br /> Address n69 -78 _ S _ <br /> f� an►;A SDR <br /> City_ 'FR A C y __ <br /> State/Zip_ w Q S 3 <br /> Phone T�r�j_ 3,N _ Z? I ec�L <br /> A. PROJECT DESCRIPTION <br /> i . Type of application: Q Use Permit, X Major Subdivision, <br /> �] 7.one Reclassificat.4cn, Q Minor Subdivision, Q Site Approval, <br /> Q Zone variance, Q Other : <br /> L . Project location: 644 E . J- R p 'RORn L-A T11 R-6 P <br /> Describe the project; i .e . , request being made a d nature of use . <br /> Tdentif.y specific project -iponents :�qz(1_L3Dl <br /> mINE Sri - . _FAm_tL_v la T5 <br /> 3 . Total acreage of project: ( # of existing parcels : O NE <br /> Assessor Parcel # (s ) :— <br /> If <br /> (s )If there i _s an existing Ei,R assessing any aspect of your project <br /> site, prc•v ide title and date : nj /A <br /> 5 . Other permits and approvals (County, Regional, State and Federal ) <br /> required for this project : <br /> PERMIT 14 AGENCY <br /> Major -: --Jision - 7 - (6/86 ) <br />