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1 <br /> 30 <br /> E E <br /> f <br /> f y, ,.,y LT�J�► <br /> A <br /> To be completed only if inventory sites are ic entified m LD. <br /> (attach additional sheets if necess Ary) <br /> 1a im ac#.on�Re <br /> p source from Propose�d�De�eloPmen't <br /> i <br /> Proposed Mitigation <br /> 2:a:Impact on Resource from Proposed Developp anent <br /> I <br /> 2.b Proposed Mitigation <br /> 'Certffrcation anti Signature$ - <br /> Stat � , a },; <br /> ement by A cant- certify that the information presented be in this f r <br /> the best of my n e Y s application �s accurate to <br /> 'nformation, and belief. <br /> 2Y 2-3 <br /> Applicant Date <br /> Page 5 of 5 <br />