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ENVIRONMENTAL CHECKLIST
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A. BACKGROUND
1.
Name of Proponent /ra �/ / 7 �/> >» a.� (/�r`•ii� /�,�? (�,;�' t,�;�
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2.
Address and Phone Number of Proponent j�/,�c�c� = �.�/• w
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3.
Date Checklist Submitted_ ,..
4.
Agency Requiring Checklist ['. ;7`✓ �i �� F'�,/,r�,,;,�/s
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5.
Name of Proposal,.if applicable Al)
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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
accurate understanding of its -scope and nature:
7.
Location of Proposal (describe the physical setting 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 environmental' setting of the proposal):
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8. Estimated Date for Completion of the Proposal / ::771
9. List of all Permits, Licenses, or Government Approvals Required for all
Proposal (federal, 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
proposal; if none has been completed, but is expected.to be filed at
some future date, describe the mature of such application form: