01214A. BACKGROUND
1. Name of Proponent
2. Addre 4 and Phone Number �fj Proponen �,
3. Date Checklist Submitted ram/
4. Agency Requiring Checklist—,,4
5. Name of Proposal, if applicable `
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6. Nature and Brief Description of Proposal (including but not limited to
its -size, general design elements, and other factors that will give an
accurst//�],'{�y�'�n er�sytandi ng�oof its scope and
enature: �//�j�
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7. Loc tion of Proposal (d cr a the physicapitsetting of the proposal, as
well as the extent of the land area affected by any environmental im-
pacts, including any other information needed to give an accurate under-
standing of the env�ronmentall�tingJthe propos
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8. Estimated Date for Completi of the Proposal
9. List of all Permits, Licenses, or Government Approvals equired for all
Proposal (�edera1, state, and local — including rezones):
10. Do you have any plans for future additions, expansions, or further
activity related to or connected with this proposal? If yes, explain.'
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11. Do you know of any plans by others which may affect the property covered
by your proposal? If yes', explain.
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12. Attach any other application form that has been completed regarding the E
proposal; if none has been completed, but is expected to be filed at
some future date, describe the nature of such application form:
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