CUE-84-76
ZOIJING ADjil5TOR FILE
CHF.CK LZST
APPLZCATIOAI NUMBER
FILING FEE PAID
4PPLICATION FORAA SUHIIRITTED
PL4T PLAN SUBIMITTED AND CHECKED
A3SESSOR'S MAP RUiJ & LEGAL DESCRIPTION DELINEATED
FILE REVIEVdED BY ZONING ADMINITRATOR
ENVIRONMENTAL CHECK LIST
ENVIRONMENTAL STAFF REVIEVIr
THRESHHOLD DETF.RMINATION
HEARING DATE SET F'OR , 19
AGENDA PAGE & PLOT PLAN SUBYvIITTED TO ENGINEER'S OFFICE
AND HEALTH DEPART1v1ENT
AGENDA PAGE SOMITTED TO OTHER AGENCIES CONCERNED
kGEAIDA PAGE MAILED T4 APPLICANT 7"--
ENGINEER'S AND HEALTH DEPARTMENT RECOIviMENDATIONS
RECEIVED
iVIINUTES V1lRITTEN
ivIIATUTES TYPED
MINUT£S MIALED TO APPLICANT 7
?oning Adjustor L'ecision Appealed to Board of Adiustment
Board of Adjustr►.mei1c Hearinq D ate Set for
Agenda Page Completed and Maileci to Property Owners
~
Agenda Page Mailed to Board flf Adiustment Members
Nlinutes Vv ritten
iYlinutes Type d
Minutes Mailed to Applicant and Eoard YvIembers
12. 11,175
Minutie^ jr"r~tt6n. TuA,r 23, 1976
CONDIAHOMI L USE PgAMi T
CUE-84-76. Uff~ct?eatftr➢sing FaCi.l?$y
a 014: NG A,DJUSTC~~ P.PCISiOFd: `r4 awwove, euhje-ot 'to *.h@ :5,110wir_q r,a;~ditioi:s:
A. CONDiTi-t?NS:
i. rtie pavec3 arEa Fl~-mll obsecve the nornral sgtbacks Y-eaatirg to dw~ll-:ng&.whicb
a;e mGr9 6gsciRCai.ly: #ro11t yard - 25 fBgt, t5'eIP yzrd -2S fGat, sid8 y8rd
five _°eat, anel fl~nki-.-ig stseet - i5 f6ot. -
Ths gaaed am& sha12 be er_clozed wish afenvae walE, or comp8ct Qpargrsen
hQdge itot to exczad &ix (6) feet in height.
3. The Va8d area shBZl be lendscaped witb everga~ena, gEBsB aII~ grirund cfl6T8T
aenti be properly mairtaftsed.
4. A " ffic anc; dvi•elcpment pler: fo: the propa►ty ±n questian 3hall te submL4ted
tvi2h 4ke eppiication.
5. The eppli,csr*_ Mhagi 11nii the parkdng to E,x~ployee€ and o:reeflott, cf cusiomes
perkAng to. rEduce ?eeiestrian trEffic eeross Su2lfvan Raad.
5. ~'te appkiEant shal$ subzr.,t e nov? eeEiqtn p<an wf.:h $et:beck Faqui.,--: ents
and lF-.zdE:•,~Pir.q gursua12 to Sect?or 4.9.4.310 uf the SpokLne Cour.ty
Zcniag Urdinazcce.
7. P,--pfou'cl e.ccasa ta IM:r_e{on : ~3lnue ky thQ SAOkests CoLa.nty Eng;~zise."'s
off?ce priot ti aeIeaEs of baiid+:~g ypem.ks. (Pc.350 pof.^Its s4wwn on
s0brmltted psot p1Gn do na~ ri_eet Lhe approval af ihe Spokane Gountgr
Engineers. )
8. T.L-.'d5ca~~~g pla, s;iall dc.:.onQ?--ais Ilghting to be defFe :ted a-qey °;a adjoin-
I.a~g reCu'if`L.4ntA.ii:a ~s7ropea-d.i.: 4A.i1'd i,:-ovAdB Nii=Ler e7iat the 8pplsc,.i-rit Lain03'Zr-~i.'„~3t~
e%-'1e;;~a'4Q scFeentn¢ frorr adjaccr_t: irmpert7r 4o the weaf. B. 03jECTO: S Oir' .?,CCRD: R ob eY': *,:r eo,ar.
LN. 310 Fines
SArskax:e, taW 59206 (Cont'd)
~
Zoning Ac~jvsto_- Minuzes
CUE-8A--76 •
July 23, 1976
Fege a
C. GsB?F,MZ, LATA:
1. Loea4fon: Settion 14, TowrA,ehip 25 1\i . , Rangs 44, 3E .W . M o .
Lotn 1& ti. Bloc!c Z, Yeradele Ptark Adc:f2ion
tog. with portion of eL-rip cf Iand 4. 0' wid:e, beinc
, r/w for iryig.canal, as said r/w now asd8ts
cxntiquous 40 and sdj. to Lots T & 2, betw"n
ext. ioL 1 ine.
Pareel No. 1454 i-OZ 28
2. A.ppktcerM. Red Lion Iaiotor L-in '
P. O. BoR 3385 .
" Spokane, WA 90W220
3. 51te 6fX0: ApptflxS.marce?y 20,640 sq. ft.
4. Existing ZoRing: Two Famil.y Residentia2, 0stab. Feb. 24~ 1952
5. Per~+.~t RSquested: so ollo:v em otf atreet garking facility.
g. Application ox ?a~,ing Prod f sion: Chmpter 4. 06 , C:ha~r 4.24. Sc3ctRons 4. 29 . C
4.310
. ..iiGH n1ng ~ ~ustar Y ~
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SVO~nM£ COUrTY COVRt 00U3K
CUE-84-76
FORM FOR (PROPOSED/IPO= DECLARATION
OF (SIGNOEM=0"ON-SIGNIFICANCE)
Description of proposal Conditional Use Permit for Off Street Parkfng in R-2 Zone
Proponent REd Lian Motor Inn
Location of Proposal SW 1/4 of SW 1/4 of Sect. 31, Township 25 N., Range 44, E.W: vI
Lead Agency qpnkana Cnunt~i
This proposal has been determined to 'OhOM/not have) a significant adverse
impact upon the environment. An EIS (IX/is not) required under RCW 43.2Ic.
030(2)(c). This decision was made after review by the lead agency of a
completEd environmental checklist and other information on file with the
lead agency.
Responsible Official DWICHT T. HL1ME
Position/Title Zonina Adiustor
Aate 7-e3-7e~, Signature
,
(3) If the form is for a declaration of environm tal significance, the
lead agency may add to the information contained in subsection (2) of this
section a listing of those environmental impacts which led to the declaration,
tcgether wfth a brief explanation of what measures, if any, could be taken
to grevent or mitigate the environmental impacts of the proposal to such an _
eactent that the lead agency would withdraw its declaration anc] issue a
(pzoposed/final) declaration of non-siqnificance. o.
STaFF ENVIRONMENTAL REVIEW
As required by WAC 197-10,-320, the staff of the County Planning Department reviewed
the envzronmental checklist submitted by Mr. Robert Suites in behalf of Red Lion Motor
Inn for a conditional use permit to allow off street parking in R-2 Z.one. The proposal
is located approximately in SW 1/4 of SW 1/4 of Section 31, Township 25 N. , Range 41
E.W. M. in the northwest corner of Sullivan and Yvlission Roads. The proponents requests
to construct an off street parking facility for 69 vehicles on a site approximately 0.5 acres
in size . The site is located on relatively flat to gently rolling terrain currently covered
by unmanaged grassland vegetation.
The staff review has identified potential areas of environmental impacts. First , and
common to nearly all types of development, is the fncrease in motor vehicle traffic
and all the effects associated therewith. These would include such impacts as
increased air pollution, specifically carbon monoxide, increased noise, increased
public safety hazards, and increased artificial lighting.
A second potential environmental impact revealed by the: staff evaluation invalves the
subsurface injection of storm water runoff. . This waste water, placed at a depth will
percolate downward toward the aquifer rather than evaporating back into the atmosphere
as under natural conditzons. A gortion of the contamination will likely be filtered out
of this waste water, but the resulting quality has not been determinEd. Appcnximately
3/4 acre-feet of storm water runoff will be generated annually and injected into the
subsurface.
The conclusion of this environmental checklist revfew is that no significant environmental
impacts will likely result from the proposal. Therefore, it is recommended that a Declara-
tion of Non-Significance be issued and an environmental impact statement not be required.
MWw . , ~
P KAfdE COUNTY
S O -q y~ a
PLANNING COMMISSION f
N. B11 JGFFfiRSON ~ pe l~~s '•~Ir~ ~ ~ J~~~S1~'rr,~~
SPOPCANE, WASHINGTON 99201 JGN3W'76
r a~~,~►~ I 3
t~4~
N . G. Arveschoug E. 11902 Mission '
Spokane, WA 99206 ~
,
197~ ~
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A
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At said time and place any interested person may appear for, or against, the granting
of this application.
SPOKANE COUiVTY PLANNING COMMISSION
ZONING ADjUSTOR HEARING TELEPHONE NO.: 456-2274
' TIME: Monday, july 12, 1976, 1:30 P. M.
PLACE: Planning Commission Conference Room
Public Works Building, N. 811 Jefferson
(Across the hall from the office)
CONDITIONAL USE PERMIT '
2. CUE-84-76, pff Street Parkina Facilitv •
a. Location: Section 14, Township 25 N., Range 44, E.W.M.
Lots 1& 2, Block 2, Veradale Park Addition
Tog. with Portion of strip of land 40' wide, being '
, r/w for irrig. canal, as said r/w now extsts conti-
guous to and adj. Lots 1& 2 between ext. lot line.
b. Applicant: Red Lion Motor Inn
P. O. Box 3385
Spokane, WA 99220
c. Site Size: Approximately 2 0, 600 sq . ft .
d. Existing 7,oning: Two Family Residential, estab. Feb. 24, 1952
e. Permit Requested: (oqafoW6- To allow an off-street parking facility.
f. Application of 7oning Provision: Chapter 4.06, Section 4.24.020-4.24.310
`
BR.450 - -
_ • J °kon e ~AY
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~VENUE
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O ; O C~ ~ a fWIC.I I't
BRI~GE o N*4506 ~
t N a:' y
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AVE 14 0! BROA.DWAY I~~ = (000~
Firc
:og~'ess= ~StatlCn
Z d Sc,hool; ~ ;
~ lx .+.1 0 ::$eC♦ r!o > .
` - 3 001 J
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SPECIAL CONDITIONAL PERMIT SPOKANE COUNTY PLANNING COMNISSI4N
NORTH 811 jEFFERSON ST,, SPOKANE VvASH,
Date -u/- p?~ " 7G Application No. : `l " 1-
(1) Narrie: -F, r' zi0 eozox /~/v (2) Phone: y' ,P000
(3) NJailing Address: Fv. 8Q /~Itate N~ ~~ld~f
Street Cit~ 7ip Code
(4) Street Address of the Property in Question: ~0~~ f ot v~Ie►~lV,~I ~ i! /~~'i,y~
(S) Legal Description: il,►_
~-..o/V : 4 L.~164r . 30 f 1_4A.4~~•.. T . .
~fad hs'u p ~ f 14/ a...~ t . ~t a~~.~
~ II tw►v.. "1i 10 &f~4~ CO/r*~ dt SAIZ,8.,cp of wI Y ~#I. FX/11~~
GN~If(I~~~ Ah iA►iAJa~ f w.7 TA. C7ij/~v/'~~If~i~i•
Section:&Efy Of /ft Township: ~ f'4/. Range:
(6) 'Lone in which the property is Iocat Ao~~4&W
Established:
(7) Provision of the Zoning Ordinance Applicable:
~ ~ -oti"
(8) Conditions for a Special Permit: YOU MUST ANSV'VER ALL OF THE FOLL~V1lING ^
Q UESTIONS:
(a) What is the nature of the Special Permit?
r C6&410ac14* OU_C~i ty/
(b) What are the specific reasons for the Special Permit?
Ai~ ~dI' ~f~d~'~/o,4~~~ ' ~ T'./ ~''Da,~~"!~v~` ~N~✓
(c) What facts support your request for a Special Permit?
?0'/ Zf& A Iw Af A/ I i ~f_1j/ I ro~ /~OA
/1
l
(d) Vdhat effect will the proposed use have on adjacent property?
(e) Vyhat interest does the applicant have in the property?
D40 ^l e
r~ .
Page 2 Special Conditional Permit Application
Spokane County Planning Commission
(9) Who hold title to the property? I4 yl-/; o l+ A-1-OA 4 *
If more than one owner, an attached list of names, addr2sses, and legal
descriptions must be submitted with this application.
0 Aplot plan or sketch must be attached containing the following information:
(a) Scale of the drawfng. (Preferred scale: 1" = 40' to 1" = 60')
(b) North point.
(c) Date.
(d) All dimensions of property, existing buildings, and proposed buildings
(e) Location of all existing and proposed buildings, or additions with
dimensions to nearest property line.
(f) Off-street parking area.
(g) Defined points of access and egress.
(h) Topaqraphic features pertinent to application, (such as rack outcrop,
canyons, hills, etc.
(11) The necessary fee must accompany this appli.cation.
I, THE UNDERSIGNED, Understand that this application must be complEte
and accurate and that all of the above requirements must be complied with
before a request may be advertised for a public hearing and that the Zoning
Adjustor may request additional pertinent information.
Sfngature of Applicant:
/~l~P .r/ ~i •A AJ~~ ivh~
IF APPROVED, CONSTRUCTION IS NOT AUTHORI2ED TIL A LAND USE O
BUILDING PERIvpIT IS ISSUED BY THE BUILDING CODES DEPARTMENT,
Spokane County Planning Commission
■
- _ - - ~ ~I
~ , _ , • . j
RED Lion moTOn nn ~
Roberi J. Suits
p + 'i~_• _ ~ r., Genorm n4nv,oqer
I JF , •
~
` ~
E Inletatate BO at oullivan Rtl.,lAalling Addrees- P O, Box 3385,
Spok,ne, 1VA 49220 I5091 924-9000 ,
~ F .
li . _ ■ _ t ~ I . ~
I SPOKarC Counir GOUMr 040U3C .
~ a . - . . 1 - • ' ' '
~i • S'TATE ot,WASHINGTON ENVI•RONMENTAL POLIGYACT Environrnental Ch~ecklist
~ .Sf~ %~~~~•~i - ~q~.r /~J l,froN
l proposal ~
I ffle number ~
~
~r
!
r i I~ t; ; t E i ~~1, n i •
SPOHANB COQNTY PLANIVIPPG COMMISSION '
PUBLIC WORNS BUILDING N. 811 JEFfERSON STREET
PHONE 466-2274
SI'OKANE, WASHINGTON 99201
Ii3TRODUCTZON: The State Environmental Poli4y Act of 1971, Chap~er 43.21C, RCW
requires all state and local governmental agencies to consider environmental
values both for their own actions and when licensing private propoeala. The
Act aleo requires that an EIS be prepared for all majo= aetions significantly
affecting the quality of the environment. The purpoae of this checklist ie to
help the agencies involved detezmine whsther or not a proposal is such a major
act ion .
. Please answer the follawinq questions as completely ae you can with the
iRformation presently available to you. Where explanations of your answers
are required, or where you believe an explanation would be helpful to govern-
men= decision makes, include your explanation in the space provfded, or.use
addit.lonal paqee if necessary. You should include refarencea to any reparts
or studies of which you are aware and which are relevant to the answers you
provide. Complete answers to these Zuestions now will help all agencies in-
'volved with your proposal to undertake the required environmental review with-
- . ~
out,unnecessary delay, -
. - ~
The following questions apply to your total proposal, not just to the
license for which you are currently applying or the proposal for which approval
is sought. Your answers should include the irVacts which will be caused by
your proposal when it is completed, even-though completion may not occur until
someotime.in the futuree This will allow all of the agencies which wfll be in-
volved to complete their environmental review naw, without duplfcEtinq paper-
work in the future. ' •
~ •
No application shall be process until the checklist has been campleted and
returned to the Pl.an Commissfon, State law reQUires explanationa for every "yes"
and "maybe" answer on the checklist and person completing the form may provide
explanations for "no" answersa
NOTE: This is a standard form being used by all state and local agencies in the
State of Waehington for varioue typee of pz•oposals. Many of the questions may
not apply to,your propasal, Tf a question does not aBAly, just anewer it "na" and
c.ontinue on to•the next queetion.
ENVIRONMENTAL CHECKLIST FORM
I. BACKGROUND
1. Name of Propanent
2. Address and Phone Number of ProD ent: '
PD~ 8. lr 33~.f . .
3. •Date Checklist Submitted___,6'`#?o?'74. •
4. Agency Requirinq Checkliet - . , S. Name of proposal, if applicablei~ ~ s1~~1 ~ ~~~/~j'~►~
• . ,
~ ' ♦
~
6_ Nature arid Brief Description of the Proposal (including but not iimited to
its size, general design elements, and othe factore that will ive an ac urate
understanding of fts scope and na'ture) : ~I~ ' ~o b i k J tl ot! Qf tf JAo. e f AW
A ee4l A 0 & " 00 A I" L
7. Location of Proposal (describe the physical setting of the proposal, as well
as Che extent of the land area affected by any environmental impactso including
any other information needed to give an a7ura unrst4nding of the environ-
mental setting of the proposal) : ol
K.' ~ <•~1r~A►~i~L.i / ~ /~f1~r_~t N /fr,.. CQ..fAt •.r
~ Estimated Date for CompleriUn of the Proposal: .
9. List of all Permits, Licenses or Govesnment Appzovals Required for the•
Fropo;,zl (federal,, state and locai including rezones) :~/~i b ~j~~i~a~
10. Do you have any plans for future additions, expansion, or further activity re-
lated to or connected with this proposal? If yes, explain: A/ v
11., Do you knaw of any plans by othersfp ich may affect the property covered by
your proposal? If yes, explain: ,/V Q
12, Attach any other appliratian form that has been completed regarding the pro-
proposal; if nons has been campletedP but is exQected to be filed at some
future date, describe the natura of such application form:
II, ENVIRONMENTAL IMPACTS '
!Explanations of all "yes" and "mayne" anmers are required)
Yes Maybe No
r,l) Earth. Will the proposal result in: ,
lat Unstable earth conditions or in changes in
geologic substructures? ~
(b) Disruptiors, displacemencs, compaction ar
overcovering of the soi 1? ~~0.4p 4r rof~
(c) Change in topogrGphy or 3roti:nd sttrface relief
features?
(d) The destruc.tion, cove=ing or mociifieation of
any unique geologic or physical feacures? ~
(e) Any increase in wind or water erosson ot soils,
either on or off ihe site7
(f) Changes in deposition or erosion of beach sands,
or changea in siltation, deposition or erosion
Yes Maybe No
wHich may modify the channel of a river or stream ~
or uhe bed of the ocean,or any bay, inlet or lake? .
Explanation:
(2) Air. Will the proposal result in:
,
(a) Air emissions or deterioration of ambi nt air
, quality?~A,0,y,i~~
(b) The creation of objectionable odore? ~
(c) Alteration of air movement, moisture or ,
temperature, or any change in climabe, either
• locally or regional y7 ~ ~
Explanation: o cG..r ~~~5 I,%,.C-,A~
~,-~-l..c:rJ~ ~ ~~l ~,..r~.~~a,.P ~iU ~,[,C~.-' ~L~ ` •
(3) Water. Will the proposal result in:
(a) Changes in currents, or the course or direction '
of water movements, in either marine or fresh
waters? ~
(b Changes in absorption rates, drainaqe patterns,
or the rate and amount of surface water runoff?
(c) Alterations to the course or fYaw of flood
' waters? ~
A(d) Change in the amount of surface water'fn any ,
water body? ~
(e) Discharge into surface waters, or in any altera-
tion of surface water quality, including but not
limited to temperature, dissolved oxygen or turbi -
dity? x
(f) Alteration of the direction or rate of flow of
ground waters?
(g) Change in the quantity of ground waters, either
through direct additions or withdrawals, or
through interception of an aquifer by cuts or ~
excarations7
(h) Deterioration in ground water quality, either ,
through direct injection, or through the seepage .
of leachate, phosphates, detergents, waterborne
virus or bacteria, or other substances into the ~
ground waters? ~
(i) Reduction in the amount of water otherwiae
- available for public water supplies?
Explanation: C) .
.~t.(.I' 4 CC6Llii . ~ L p
G m
(4) Flora> Will the proposal resu /tin':
(a) Change in the diversity of speciea, or numbere
of any species of flora (including trees, shrubs,
graes, crope, microflora and aquatic plants)? X
(b) Reduction of the numbers of any unique, rare or ~
endangered species of flora?
. y
. Yes Niaybe No
(c) Introduction of new species of flora into an area,
or in a barrier to the normal replenishment of
existing species?
(d) Reduction in acreage of any agricultural crop?
Explanation:
(5) Fauna. Will the proposal result in:
(a) Changes in the diversity of species, or numbers of
any species of fauna (bizds, land animals including
reptiles, fish and shellfish, benthic organisms, ~
insects or microfauna)?
(b) Reduction of the numbers of any unique, rare or
endangered species of fauna? ~
(c) Introduction of new species of fauna into an area,
or result in a barrier to the migration or movement
of fauna? ~
(d) Deterioration to existing fish or wildlife habitat?
Explanation:
(6) Noise. Will the propos i cr ase exi ting no'se levels? x
Explanation: C.~I►1 Iri ~a Q d N ~Q1► !~/e 16ftw fkv 1044#~Fo
V-P .e
(7) Liqht and Glase> Will the proposal psoduce new light ar
E? x
ation: , vt (.11►f ON Z
_,Y-- W Nlf A1
(8) Land Use. Will the proposal result in the alteratio;i of
the present or p anned lari use o-C aAn ared ~
Explanation:
F- r
(9) Natural Resources. Will the proposal result in:
(a) Increase in the rate of use of nay natural resources? ~
(b) Depletion of any nonrenewable natural resource? X
Explanation:
(10) Risk of Upset. Does the propasal involve a risk of an
explosion or the release of hazardous substances (including,
but not limited tr oil, pesticides, chemicals or radiation)
in the event of an accident or upset conditions? ~
Explanation:
(11) PoPulation. Will the proposal alter the location, dis-
tribution, density, or growth rate of the human papu-
lation of an area? ~
Explanation:
(12) Housina. will the proposal affect existing housing, or
create a demand for additional housing? ~
Explanation:
4, .
Yes Maybe No
(13) 'Transportation/Circulation. Wili the proposal result in:
(a) Generation of additional vehicular movement?
(b) Effects on existing parking facilities, or demand
for new parking?
(c) Impact upon existing transportation systems? ~
(d) Alterations to present patterns of circu} tion ar
movement of people and/or goods? %~•o~i 4~•~l~~A~J A*
(e) Alterations to waterborne, rail or air traffic7 _
(f) Lncrease in =raffic hazazds to motor vehicles,
bicyclists or pedestrians?
Explanat ion : ~ , Io 9 ~E..at.GC.aF~,~.~ l~r►- ~v~~~s
. L
C)
(14) Public Services, tvill the proposal have an effect upon,
or result in a rieed ior new or altered goveznmental services ~
in any of the following areas: ~
(a) Fire protection? 1~ ~C
(b) Police protectioni y
(c) Schools? ~
(d) Parks or othea recreational facilities? ~
(e) Maintenance of public facilities, including roads? X
(f) Other governmental se vices?
Explanation: ~~i`. A
OW
(15) EnerctY. Will the proposal result in:
(a) Use of substanr.ial amounts of fuel or energy?
(b) Demand upon existing sources of energy, or require
the development of new sources af energy? ~
Explanation: .
(16) Uti2ities. Will the propasal result in a need for new
systems, or 3lterations to the following utilities:
(a) Power or natural gas? ~
(b) ,Communications systems7 . ~
(c) water?
(d) Sewer or septic tviks? ~
(e) Storm water drainage?
(f) Solid waste and c3isposal?
Explanation:__g~,.
(17) Human Health. Will the proposal result in the creation of
any health hazard or potential health hazard (excluding
mental health) ? x
Explanation:
Yes Maybe No
(18) Aesthetics. S1i11 the proposal result in the abstruction
of any s,cenic vista or view open to!the public, or will
the proposal result in the creation of art aesthetically
oXf~fensive site opp~lic v~ew~~ ~ ~A-
I ~
(19) E Ianation: ,~Q,e~
Recreation.. Will the proposal result in an impact upon
the quality or quantity of existing recreational
opportunities? ~
ExpLanation:
(20) Archeolaqical/Historical. Will the proposal result in an
alteration of a significant archeological or historical ~
site, structure, object or bulldfng7
Explanation:
(21) Additional Information.
IIZ. SIGNATURE
I, the undereigned, state thdt to the best of my ;cnowledge the abotie information
ie true and complete. It is understood that the lead agency may withdraw any declara-
tion of non-significance that it might issue in reliance upon this checklist should
there be aEiy willful miarepresentation or willful lack of full disclosure on my part.
Proponent:.90/74o#v 0 0 1ON ~N
Address: F Jed fmke,&.r 4"&,`
Phone : f-~, ~ 9e e e►
Person completing forrn:
Phonea " •
Date: •
, ~ ~ ~2 ~ ~~-7 6,
JOB NUh!RER ; `.9G2C3 r, A L ~ ° 5 k ; F t I . ha L [ ~ -JII NE-- 4 , I 1*'P 6
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