Page 109 - _ 180314 Special Yucaipa GSA Packet
P. 109

(a) Continued  Applicant Authorized Agent Name


         Authorized Agent Title and Affiliation

         Agent Mailing Address




         City                     County                      State               Zip


         Email                                   FAX                                      Phone (office)

                                                                                          Phone (cell)


                               (b) – (c) – (d) – (e)Other Permits/Licenses/Agreements/Plans
                            (attach copies to this notification as described in the instructions)
          (b) & (c) Federal  (Type and Permit/License Number)



          (d) State (Type and Permit/License/Agreement Number)



          (e) Other County, City, etc. (Type and Permit/License Number)



          Other Required Documents or Plans (for example SWPPP)




                                                          (f) CEQA
         CEQA Notice of Exemption (exemption name
         and number)


         Notice of Completion or Notice Availability



         Attach draft or final CEQA Notice of Exemption, Notice of Completion or Notice of Availability.
         Staff may request copes of all CEQA documents if needed to evaluate the project.




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                                  Yucaipa Groundwater Sustainability Agency - March 14, 2018 - Page 105 of 226
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