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Environmental Information <br />s ` <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 f <br />Answer all questions <br />is not applicable to <br />Please do not leave <br />PERSON COMPLETING FORM <br />Address_ <br />City <br />State Zj <br />Phone <br />TYPE OF APPLICATION <br />orm, use additional sheets if necessary. <br />to the best of your ability. If question <br />your project, write NA (not applicable). <br />blanks. Incomplete forms cannot be accepted. <br />PROPERTY OWNER <br />e. <br />AGENT OF OWNER <br />PROJECT (P Vffy CZ UiZ /��- �2 Edi n YT1 Yit� �iii�, <br />OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br />REQUIRED FOR THIS PROJECT <br />PERMIT AGENCY- <br />-1 - <br />Plan -44 (12/85) <br />(9/85) <br />