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r � <br /> For Staff Use Only <br /> File No ._ 5U- 67-3 _ <br /> Date Filed l/-fQ- O& <br /> APPLICATION FORM PART B: <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 OWNER X AGENT OF OWNER <br /> Name Robert "_ichardson _ <br /> Address <br /> City 26800 SO. HANSEN ROAD <br /> State/Zip_ TRACY, CALIFORNIA 95376 ^^� <br /> Phone 209)835-8682 <br /> TYPE OF APPLICATION Major Subdivision <br /> PROJECT See eavlanation attached to Application form. <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT AGENCY <br /> None known. <br /> -1- ( 9/85 ) <br />