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Environmental Information <br /> r. 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 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 AGENT OF OWNER <br /> Name L . JRAiA (SA ri . A71iAI2An0 <br /> Address 7 l C iA7t)i. FE Re) As) <br /> CitrniC` t-L Am (� <br /> State/Zip t°g _ q .3 i _ <br /> Phone <br /> TYPE OF APPLICATION r Kc3 v ro / <br /> PROJECT <br /> le LA —ihRnl? <br /> OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br /> REQUIRED FOR THIS PROJECT <br /> PERMIT AGENCY <br /> -1- ( 9/85) <br /> Plan-44 (12/85) <br />