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19 <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 /> 1.b. Proposed Mitigation <br /> 2.a. Impact on Resource from Proposed Development <br /> 2.b. Proposed Mitigation <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, infor ation, and belief. <br /> JJZY�7M �' S march 2- <br /> Applicant <br /> Z <br /> Applicant Date <br /> Page 5 of 5 <br />