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_L <br />Environmental Information <br />c <br />r <br />lM is <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 X AGENT OF OWNER <br />Name <br />Address <br />City <br />Stat <br />Phon <br />TYPE OF APPLICATION TSOTATWE SUBOWISOJ MAP <br />PROJECT <br />L <br />OTHER PERMITS AND APPROVALS (COUNTY, REGIONAL, STATE AND FEDERAL) <br />REQUIRED FOR THIS PROJECT <br />PERMIT <br />Plan -44 (12/85) <br />AGENCY <br />-1- <br />(9/85) <br />N <br />