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°'- Environmental Information <br />For Str:ff Use Only <br />File No. <br />Date Filed ` '- <br />APPLICATION FORM PANT U: <br />ENVIRONMENTAL INFORMATION <br />('To be Filled Out 9y 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 <br />Name Dan T <br />Address -11016_ <br />City_ Modes <br />StateH p_ -Ca <br />Phone__'__5Z1-_d <br />TYPE OF APPLICATION <br />PROPERTY OWNER <br />X _AGENT OF oWNE)a <br />C. <br />Major subdivision - zone reclassification <br />PROJECT_ Z6 Sln_g_Le._fami1 racirlanti- <br />�'----�1_suhd.iu_i.sio.n.._..__.._________ <br />UTHEH PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br />REQUIRED FOR THIS PROJECT <br />PERMIT <br />AGENCY <br />-1- <br />:.in (9/85) <br />