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- Iironmental Information <br /> For Staff Use only <br /> File No. <br /> Date Filed <br /> APPLICATION FORM PAI(T li: <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 OWNE14 V'-AGENT OF OWNER <br /> Name R61V-R (CAN yAQW&S 7i— LOI\O <br /> Address _.F.,D <br /> 030 ------------------ --- <br /> Phone------ -1� --- ------- --------------- -- <br /> TYPE OF APPLICATION MIWOK- SUaDWLS;joN <br /> PROJECT_ L-OT 9ZAL Rs�oF<Chlr�f\l� sUE3p(Olsla(�r <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT AGENCY <br /> - -- ------- - - .._--_--.-_- __-_.-.__-_�-----_.___ - <br /> -l- ( 4/85 ) <br /> 112 '851 \ <br /> 1 . <br />