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Page 5 of 5 <br /> <br /> <br />Attachment A <br />To be completed only if inventory sites are identified in I.D. <br />(attach additional sheets if necessary) <br />1.a. Impact on Resource from Proposed Development <br /> <br /> <br /> <br /> <br /> <br />1.b. Proposed Mitigation <br /> <br /> <br /> <br /> <br /> <br />2.a. Impact on Resource from Proposed Development <br /> <br /> <br /> <br /> <br /> <br />2.b. Proposed Mitigation <br /> <br /> <br /> <br /> <br /> <br />Certification and Signatures <br />Statement by Applicant - I certify that the information presented by me in this application is accurate to <br />the best of my knowledge, information, and belief. <br /> <br />___________________________________________________ <br /> <br />___________________________________________________ <br />Applicant Date <br /> <br />51