HomeMy WebLinkAboutEnvironmental Checklist - SEP Determinations - 2/27/1989 MASON COUNTY
DEPARTMENT of GENERAL SERVICES
Courthouse Annex I N. Fourth & W. Cedar
P.O. Box 186 Shelton, Washington 98584
(206) 427-9670
building environmental health maintenance landfill parks&recreation fair/convention center planning sewer&water
Dennis Shumaker �Q' February 27 , 1989
NE 241 Riverside Place
Belfair, WA . 98528 �V01��YJ�
jl�01�1 4U Gf
.
Dear Mr . Shumaker, C �J V'
CG
In reviewing the Environmental Checklist submitted by you to
the Department of General Services the Director of General Services
has reached a threshold Determination of Significance rather than
the Determination of Nonsignificance which I had assumed . This
will require additional information submitted by you and/or the
company assisting you. The lead agency has identified the
following areas for discussion :
- Nature of discharge material .
- Impact of water usage from source .
- Storage of fish waste .
- Use of pasture land for settling basin .
- Effect of pumping shallow wells on water source .
- Pumping fish waste to pasture land .
- Structure of settling basin .
If you are able to address all of the above issues and the Director
of General Services feels they have been adequately addressed the
County may at that time issue a Determination of Nonsignificance
for your proposal . Thank you.
Sincerely ,
�QU ,` t
Grace Miller , Planner
Dept . of General Services
GM/gm
l
APPLICANTS RIGHTS AND RESPONSIBILITIES
At the Conceptual State WAG 197-11-055
1. If an agency's only action is a decision on a license or permit that
requires detailed project plans and specifications, the agency shall
provide the applicant with the opportunity for environmental review under
SEPA before requiring the applicant to submit such detailed project plans
and specifications. Agencies may specify the amount of detail needed
from applicants for such early environmental review.
2. There is nothing in SEPA that precludes agencies or applicants from
preliminary discussions or exploration of ideas and options before
starting formal environmental review.
Threshold Determination WAG 197-11-100
1. An applicant usually will be required to complete the environmental
checklist in connection with filing an application. Additional
information may be required at the applicant's expense, but not until
after initial checklist review.
2. Prior to a threshold determination, the lead agency may require field
investigations and/or research by the applicant reasonably related to
determining a project's environmental impacts.
3. An applicant may clarify or revise the checklist at any time prior to
a threshold determination.
4. Upon request by an applicant, the responsible official shall select a
date for making a threshold determination and notify the applicant of
such date in writing (WAC 197-11-310) .
5. If a DNS was procured by misrepresentation or lack of material
disclosure, and if this resulted from the actions of the applicant, any
subsequent environmental checklist on the proposal shall be prepared
directly by the lead agency or its consultant at the expense of the
applicant (WAC 197-11-340) .
6. After submission of an environmental checklist and before the lead
agency issues a threshold determination, an applicant may ask the lead
agency to indicate whether it is considering an EIS. If so, the
applicant may clarify or change features of the proposal to mitigate the
adverse impacts that would have caused the lead agency to require an EIS
(WAC 197-11-350) .
0-1
DETERMINATION OF SIGNIFICANCE
AND REQUEST FOR COMMENTS ON SCOPE OF EIS
Description of Proposal:
Proponent: h is slicci»Ct,�¢�
Location of Proposal: 1l o�y/ IC/Ve�'SiQ�e �lQ��/�t�(cz/i NENE a0- 23 -/
Lead Agency: Cctryi C-Bsvjo�•��j^Q �� ��
EIS REQUIRED. The lead agency has determined this proposal is likely to
have a significant adverse impact on the environment. An environmental
impact statement (EIS) is required under RCW 43.21C.030( 2)( c) and will be
prepared. An environmental checklist or other materials indicating likely
environmental impacts can be reviewed at our offices.
The lead agency has identified the following are/as for discussion ,in the
EIS: IV C44,�-,L,g /n�lru��_GYk/�J/�if//ir1 y /iAnni tr�h. SIV'Ae,•S&?aye
uQ cgo- T GcrCP ?7S�
wasje fo' s4 j S � St� wq haSr.,
SCOPING: Agencies affected tribes, aruF members of the public are invited to
comment on the scope of the EIS. You may comment on alternatives,
mitigation measures, probable significant adverse impacts, and licenses or
other approvals that may be required. The method and deadline for giving us
your comment is:
Responsible Official: i' ���u
7
Position/Title:
Address: 0, ;�"PX lee, 5xx- e6rll
Date: Y7 Signature:
You may appeal this determination of significance
to
yl�
� �YIM.�f��!ZZ
at �//I /1/oi�'% 6r� "`"Ti '
;> no later than
O•
You should be prepared to make specific factual objections.
Contact w -44& " to read or ask about the
procedures for SEPA appeals.
GUI�G ybIMNO Ao/NT?'EATS/ f0(/NG/C. HC/EC� A/�OG t CAit7T
G(J,DLcI �-S,�UKOtif/SH Tip/L3E �L�CrC
/v ru-c91�oZe GcJ1 LAot,
Part Eleven-197-11-980 SEPA Rules
RCW 197-11-980 Determination of significance and scoping notice (DS).
DETERMINATION OF SIGNIFICANCE
AND REQUEST FOR COMMENTS ON SCOPE OF EIS
Description of proposal
Proponent
Location of proposal
Lead agency 0_ eW_-N COJJ/'JC"l �CLC t
1
EIS Required. The lead agency has determined this proposal is likely to have a significant adverse impact on the en-
vironment. An environmental impact statement (EIS) is required under RCW 43.21C.030(2)(c) and will be prepared.
An environmental checklist or other materials indicating likely environmental impacts can be reviewed at our offices.
The lead agency has identified the following areas for discussion in the EIS: WiTUCC Or 1)L6C4AW*f AAA-T*_p4A-1-"
ltt,l eAC—i Of WAT*i _ u6A6 E F"M Sdoer-E 5-me04f- 41c PtSN 1 &,5T *- ;
V•5+z OF FAKU,�-ra ►-4#-30 F04 13A510 rLTrEGT dir 1�V VAp1 J6 561AL117W
a1.1 W�'TE�2 SOv2C f_� 1, NrA f?10r- F1S14 WASTE TO yASTUieC L-AMV , 5Y�c TueK ot= SeTTL%W-
ao.'sIN ,
Scoping. Agencies, affected tribes, and members of the public are invited to comment on the scope of the EIS. You
may comment on alternatives, mitigation measures, probable significant adverse impacts, and licenses or other ap-
provals that may be required. The method and deadline for giving us your comments is:
LtDr
Responsible official m 11 X_ "ts4yKs"
Position/title -C.�Z�I1� p Phone
Address (� Mx �J� t ��C`�►"l l O-� '1
Date Signature
(OPTIONAL)
❑ You may appeal this determination of signi Icance
to (name)
at (location) fi LL �i
no later than (date) 155VC'4J T
by (method) Lori tte,v� C'ayY�V1,�c�
You should be prepared to make specific factual objections.
Contact to read or ask about the procedures
for SEPA appeals.
❑ There is no agency appeal.
(Ch. 197-11 RCW—p 541 (1983 Laws)
I
ENVIRONMENTAL CHECKLIST
Purpose of Checklist
The State Environmental Policy Act ( SEPA) , Chapter 43. 21C RCN, requires
all governmental agencies to consider the environmental impacts of a
proposal before making decisions. An Environmental Impact Statement (EIS)
must be prepared for all proposals with probable significant adverse
Impacts on the quality of the environment. The purpose of this checklist
is to provide information to help you and the agency identify impacts from
your proposal (and to reduce or avoid impacts from the proposal , If it can
be done) and to help the agency decide whether an EIS is required.
Instructions for Applicants
This Environmental Checklist asks you to describe some basic information
about your proposal . Governmental agencies use this checklist to
determine whether environmental impacts of your proposal are significant, .
requiring preparation of an EIS. Answer the questions briefly, with the
most precise information known, or give the best description you can.
You must answer each question accurately and carefully , to the best of
your knowledge. In most cases, you should be able to answer the questions
from your own observations or project plans without the need to hire
experts. If you really do not know the answer, or if a question does not
apply to your proposal , write "do not know" or "does not apply•. Complete
answers to the questions now may avoid unnecessary delays later.
Some questions ask about governmental regulations, such as zoning ,
shoreline, and landmark designations. Answer these questions If you can.
If you have problems, the governmental agencies can assist you.
The checklist questions apply to all parts of your proposal , even if you
plan to do then over a period of time or on different parcels of land.
Attach any additional Information that will describe your proposal or Its
environmental effects. The agency to which you submit this checklist may
ask you to explain your answers or provide additional Information
reasonably related to determining If there may be significant adverse
Impact.
Use of Checklist for Nonproject Proposals
Complete this checklist for nonproject proposals , even though questions
may be answered "does not apply." iN ADDITION, complete the SUPPLEMENTAL
SHEET FOR NONPROJECT ACTIONS (Part D).
For nonproject actions, the references In the checklist to the words
" project, " "applicant, " and "property or site■ should be read as
"proposal ," "proposer," and "affected geographic area, " respectively.
A. BACKGROUND
1 . Name of proposed project, If applicable:
L>'pulo,J 21
ENVIRONMENTAL CHECKLIST
2. Name of applicant: � iU,S (C{�T�1� �►v1A �
3. Address and telephone number of `applicant and contact person:
AJF zqi K►oc2sioz PL
OF-L R/}12 , WA ' 8szs
,?-75-16'77
4. Date checklist prepared: Z
5. Agency requesting checklist: 0 COC�N?./ PLAA.)IVI ✓6 �✓R-/fl^
6. Proposed timing or schedule ( including phasing, if applicable) :
_ _ t
7. Do you have any plans for future additions, expansion, or further
activity related to or connected with this proposal? If yes, explain.
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vivo o(Z T-4RTWr-#J RA C,,JL "+ys .
8. List any environmental information you know about that has been
prepared, or will be prepared. directly related to this proposal.
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I S $r,N t, pv�ti By F(5/4 Pao T'uc-. Po2r
9. Do you know whether applications are pending for governmental
approvals of other proposals directly affecting the property covered by
your proposal? if yes, explain. �2w��T �tL,,4-
0 i -
10. List any government approvals or permits that will be needed for your
proposal , If known. 6t)A,7-CP- �2j6►+T- FiZo-,- b.o.L,
Z)ISCi+42(oE[ f XkN9t1 F(Lox-, ().0
i1 . Give brief, complete description of your proposal , Including the
proposed uses and size of the project and site. There are several
questions later In this checklist that ask you to describe certain aspects
of your proposal . you do not need to repeat those answers on this page.
'To Sr TA 2T .4 S Nil A L(- F4M%L-y (3�(S I N -sS �2 K4 7 -Am
By 14 0 Lk r2 LA00 A,-U6 (, A-fre- OAJ oq: PAR9k T-0 2t�,sr' plsr� .
Nk AOn;(,(gL Ptipuc7-fW WILL 57AA-7' AT 600 !b A y r_r
AMD SOME DRy (Al TOE FuT"-F- G o NP -*Tfl 401 Doc(%IRQ E W r- "A"W Tor- UJAMR.
-2-
ENVIRONMENTAL CHECKLIST
12. Location of the proposal . Give sufficient information for a person
to understand the precise location of your proposed project, including a
street address, if any, and section, township, and range. if a proposal
would occur over a range of area, provide the range or boundaries of the
site(s). Provide a legal description, site plan, vicinity map.
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TO BE COMPLETED By APPLICANT
B. ENVIRONMENTAL ELEMENTS
1. Earth
(a') General description of the site (circle one) : fiat rolling, hIIly ,
steep slopes, mountainous, otherk' Nijo+2 Vex R SH.I:Dy M«�•
(b) What Is the steepest slope on the site (approximate percent slope)?
(c) What general types of soils are found on the site (for example, clay,
sand, gravel , peat, muck)? If you know the classification of agricultural
soils, specify them and note any prime farmland. 7-4,, ptVT (zlTvZ UA y
L.ycAr—D WPTH
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(d) Are there surface indi-cations or history of unstable soils In the
immediate vicinity? 1f so, describe. 17-(t65/0P✓ 41-041& 7-AW 6(N/ia(d e,.JC2
•b 0._ bTrl e 4:k F P T W Jr-7- PAS 7u 12-E (FO A1)
(e) Describe the purpose, type, and approximate quantities of any filling
or grading proposed. Indicate source of fill . � q��q/y of SI DES � BA�UKS
r �
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F A BV-5-( -VUz0 DOuoL,: 0tsCfh42GE 5fTTL►►)&. GA-r/Iv, /(IOoo c.kFT t-
+ TE 5i*wp E G:*?AVCL
( f) Could erosion occur as a result of clearing, construction, or use? If
so, generally describe. 41L W(LL /j/. pA/ )r2t4T G,J�O/ TMr-X)
GQAvf��- f)/ZkUru1A•1tJ3 HI SS �'iLLS /N/ 'fthc lZCST,
( g) About what percent of the site will be covered with impervious
surfaces after project construction (for example, asphalt or buildings) ?
� E .SFW�,o -� Sct/Z rz4cPz. PUoL 5
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-3-
ENVIRONMENTAL CHECKLIST
(h) Proposed measures to reduce or control erosion, or other impacts to
the earth, if any:
• l��"5E1�0 A� 6�� ,�A�e,Tr� � u� o�
Rip Rip • w H�� J�1�f�p�i�, . -
2. Air
(a) What types of emissions to the air would result from the proposal
( i .e., dust, automobile, odors, industrial wood smoke) during construction
and when the project is completed? If any, generally describe and give
approximate quantities if known. �= i
D/E.>E*L 4 6: Sott1U� �xNr'��tS7-
•PR 1)
Iry y Qu i)7.Jk�-IJ _ D�AP I AJC, COSTS uc7�0 it7
•;. _ _ �4 _ACT
_ . •__ -_ -= (b)- .Are:there -an-y off—site sources of emmissions or cdor- that may affect.•.'
your' proposel? _ 1f 'so, generally describe.
15 H WAS T♦ G<liw IaE G!S>�� ,�l s ;�.Q�'Lt Z�E2 ` Soi D/
(c) Proposed measures to reduce or control emissions or other impacts to
air, If any:
eaX 3y c%97 R
- lain,';, /Jf►2�'aLLy B�� , DD C-u v
3. ?later
(a) Surface
1 ) :1s there any surface water body on or in the immediate vicinity of the - _
site (including year=round and seasonal streams, saltwater, lakes. ' ponds,
wetlands)? if yes, describe type and provide names. _If appropriate, state
what stream or river it flows Into 4 .SI,R*4-c- yg+q_ Ako-wo• Pet s-D SrRr,"
_7W O '. OxIS 7-1 lu O , JDoNOS AND T&*c V(A)(LAl 12111EIZ
o�= wf:St&,eLy PoN p
2) Will the project require any work over, in, or adjacent to (withn 200 -
feet) the described waters? If yes, please describe and attach available
plans. `- RE:
�N>t Po,010 PkiRi: 5 H-,4PE jD
3) Estimate the amount of fill and dredge material that would be placed
In or removed from surface water or wetlands and indicate the area of the
site that would be affected. Indicate the source of fill material.
Lf'S inJ v A T04SI4 4�4 t+st J
s I lmkADDy W4MP, w►tt- 6C PL41"peD 175 ' FAST or- PZvraoSa-6
5 k,TTl I Nv f.)HS-W /V72o �} LOW w ET 19,457urt�
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ENVIRONMENTAL CHECKLIST
4) Will the proposal require surface water withdrawals or diversions?
Give general description, purpose, and approximate Quantities If known.
%vIi,tp7i) %Pe'!A kit LLOcv Cl SAc.� l�s, xrs�ti� PcwOS
�J FFi z It; i It is L=k_�r-h `
t'+S1AJ .
5) Does the proposal lie within a 100-year floodplaln? If so, note -
location on on the site plan.
_ hl v
6) Does the proposal involve any discharges of waste materials to surface
waters? If so, describe the type of waste and anticipated volume of
discharge. PCB _-fit;/f��.%�tl 4C!'QV�O �y i�7�1i 0-4- dLUt7y
(b) Ground ,-
1 ) Mill ground water be withdrawn, or wlII water- be discharged to ground
water? Give general description, purpose, and approximate quantities If
known. 4-00 - (9C)�
9 �� I.�J17►+i�Rl�cvN Rhl5i )=isH 1AJ
2) Describe waste material that wlII be discharged into the ground from
r septic tanks or other sources, if any for example: domestic sewage;
Industrial, containing the following chemicals ...; agricultural ; etc. ) .
Describe the general size of the system, the number of such systems , the
number of houses to be served ( if applicable), or the number of animals or
humans the systen(s) are expected to serve.
THE OVL�
C tS Ll►�
15N (,U ST IZ_(TER
(c) Mafar Runoff ( including storm water)
1 ) Describe the source of runoff ( including storm water ) and method of
collection and disposal, if any ( include quantities, if known) . Where
will this water flow? Mill this water flow into other water? If so,
describe. � � LI Lrc `LAiL' <�' 43 90 /NTO
2) Could waste materials enter ground or surface waters? If so, generally
describe.
LJ N 1?('kA)CF1=
wc:1
ENVIRONMENTAL CHECKLIST
(d) Proposed measures to reduce or control surface, ground, and runoff n
water impacts, If any: N( k i�I�rto �•'-i TL/ n/(o 1�f�5'/r� l�',t L��� r1 4,��
4. Plants
(a) Check or circle types of ve etation found on the site:
deciduous tree: as
maple aspen, other
evergreen tree: fir edar, pine, other
shrubs
L grass
crop or grain --
wet soil plants: cattail , buttercup, bullrush skunk cabbage, other
rater plants: water illy, eelgrass, milfoll, other LvA7>FIZCRE5S
other types of vegetation
` - (b)^ What kind-and amount of vegetation rill be removed -or altered?
�5 Q 6 SQ P�T- o f PHi7u9 CviL►�__S
(c) List threatened or endangered species known to be on or near the
site. �RflI�IF15rl (NS,I e TS
(d) Proposed landscaping, use of native plants, or other measures to
preserve or enhance vegetation on the site, if any:
�aSSr 6c� C ,�h r�i� ,f-fE��� �2 S�►'Ane_ r F-{:�L�, .a�{11! � W/'h1a11
5. Animals
(a) Circle any birds and animals which have been observed on or near the
site or are known to be on or near the site:birds: hark, heron. eagle, songbirds, other: Dt4ciCs i OlubF(Sdcl
mammals: deer, bear, elk, beaver, other: 1V1a5' r,0_A-7-_- kYA_rAjlow fth_ lS)6
fish: bass, salmon, trout, herring, shellfish, other: c_'J�Wp"- f
(b) List any threatened or endangered species known to be on or near the
site.
(c) Is the site part of a migration route? If so explain.
S'CAGuc.e_s &UvR_Hw,4v' �G- ,'T ��T .c/ ��/,�AC� DuW P
(d) Proposed measures to preserve or enhance wildlife, if any:
A.
-6-
ENVIRONMENTAL CHECKLIST
6. Energy and Natural Resources
(a) What kinds of energy �lectrl natural gas, ol1 , wood stove, solar)
will be used to meet the completed project' s energy needs? Describe
whether it will be used for heating, manuffacturing, etc.
14A 0 jZ�•�_`>
(b) Would your project affect the potential use of solar energy by
adjacent properties? If so, generally describe.
Al
(c) What kinds of energy conservation features are included in the plans
of this proposal? List other proposed measures to reduce or control energy
impacts, if any:
7. Environmental Health
(a) Are there any environmental health hazards, including exposure to
toxic chemicals, risk of fire and explosion, split , or hazardous waste,
that could occur as a result of this proposal? If so, describe.
r ..
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ntsiNFEC i F150-4 E7NviP_oviA"7' A)er 4t3P12-vvCD /3y S7%�714F,
1) Describe special e/lmergency services that eight be required.
- : PEEP �u�lpsu►VA1i�i76 =
2) Proposed measures to reduce or control environmental health hazards,
if any: I
iron—
(b) Noise
1 ) What types of noise exist in the area which may affect your project
( for example: traffic, equipment, operation, other)?
2) What types and levels of noise would be created by or associated with
the project on a short-term or a long-term basis ( for example: traffic
construction, operation, other)? Indicate what hours noise would come from
the site. 1kAoy IzCj%Uil?ivt ,: 0U2uJ(=> p�gT�m -io CON57I��fCT
AS N DrTCrtFs
LON�TIZe�'►vl JI/_ L /lam L,/A-�2 kLf A1N/ill Cy c SPIHS //✓G
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-7-
ENVIRONMENTAL CHECKLIST
3) Proposed measures to reduce or control noise impacts, if any:
AJOloa
B. Land and Shoreline Use
(a) What is the current use of the site and adjacent properties?
NLT lie�A;GL-t s R-U
(b) Has the site been used for agriculture? If so, describe.
(c) Describe any structures on the site. t
(d) Will any structures be demolished? If so, what?
/VJ
(e) What is the current zoning classification of the site?
(f) What is the current comprehensive plan designation of the site?
N5ti�
(g) If applicable, what Is the current shoreline master program
designation of the site?
(h) Has any part of the site been classified as an "environmentally
sensitive" area? If so, specify.
( 1 ) Approximately how many people would reside or work in the completed
project? -7 bK Pf;7-7- 5i ruL� 7tua
(j) Approximately how many people would the completed project displace?
N6c 16
(k) Proposed measures to avoid or reduce displacement impacts, if any:
( 1 ) Proposed measures to ensure the proposal is compatible with existing
and projected land uses and plans, if any:
51 Tz /5
-e-
ENVIRONMENTAL CHECKLIST
9. Housinq
(a) Approximately how many units. would be provided, if any? Indicate
whether high, middle, or low-income housing. .
IfIVA/l'
(b) Approximately how many units, If any, would be eliminated? Indicate
whether high, middle, or low-income housing.
Awe
(c) Proposed measures to reduce or control housing impacts, If any:
i -
. 1lf Qrv�
10. Aesthetics .
(a) , What 1s the tallest height of an proposed structure( s ) , not -
Inciuding-antennas; what is the principal exterior buliding materlal (s)
proposed? . �(tp sGO �no�c 6� �t z0 wit.- ram, 2 S%n�/
(b) What views in the immediate vicinity would be altered or obstructed?
(c) Proposed measures to reduce or control aesthetic impact, If any:
11. Light and Glare
(a) What type of light or glare will the proposal produce? What time of
day would 1t mainly occur?
(b) Could light or glare from the finished project be a safety hazard or
interfere with views?
NO
(c) What existing off-site sources of light or glare may affect your
proposal?
(d) Proposed measures to reduce -or control light and glare impacts, if
any:
12. Recreation
(a) What designated and informal recreational opportunities - are in the
immediate vicinity?
Fr S rr-,N G /p/ /,/vie•✓ 4(/fi!-C
-9-
ENVIRONMENTAL CHECKLIST
(b) Mould the proposed project displace any existing recreational uses?
If so, describe.
(c) Proposed measures to reduce or control impacts on recreation,
including recreation opportunities to be provided by the project or
applicant, if any:
/Vc„re
13. Historic and Cultural Preservation
(a) Are there any places or objects listed on, or proposed for, national,
state, or local preservation- registers known to be on or next to the site?
If so, generally describe.
NC
(b) Generally describe any landmarks or evidence of historic,
archaeological , scientific, or cultural Importance known to be on or next
to the site.
• . /V t�tir�E
(c) Proposed measures to reduce or control impacts, if any:
14. Transportation
(a) Identify public streets and highways serving the site, and describe
proposed access to the existing street system. Show on site plans, if
any.
(b) is site currently served by public transit? If not, what Is the
approximate distance to the nearest transit stop?
/4 U 41 1-C 5 %a
(c) How many parking spaces would the completed project have? How many
would the project eliminate?
FocAe 5PAces 6A, sirF
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-10-
ENVIRONMENTAL CHECKLIST
(d) M111 the proposal require any new roads or streets, or improvements
to existing roads or streets, not including driveways? If so, generally
describe ( indicate whether public or private) .
(a) M111 the project use (or occur in the immediate vicinity of ) water,
rail, or air transportation? If so, generally describe.
v-
(f) How many vehicular trips per day would be generated by the completed
project? if known, indicate when peak volumes would occur.
(g) Proposed measures to reduce or control transportation impacts, if
any:
15. Public Services
(a) Mould the project result In an increased need for public services
( for example: fire protection, police protection, health care, schools,
other)? if so, generally describe.
(b) Proposed measures to- reduce or control direct impacts on public
services, If any.
16. Utilities
(a) Circle utllitles currently aval at the site: electricity,
natural gas Ovate refuse services telephone sanitary serer, optic
system, other:
( b) Describe the utllitles that are proposed for the project, the utility
providing the service, and the general construction activities on the site
or in the immediate vicinity which might be needed.
P. L. , ). w,t-i- Bslin» T#-P)E �' gs� Nowt;w' 7a Si79-
OLD &tppl R PI IA,&l
C. Slgnature
The above answers are true and complete to the best of my knowledge. I
understand that the lead agency is r lying gn them to make its decision.
Signature:
(!
Date Submitted:
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