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*ENVIRONMENTAL DECLARATION <br />(CALIFORNIA FISH AND GAME CODE SEC. 711.4)�'�n. �® <br />FOR COURT USE ONLY <br />NAME AND ADDRESS OF APPLICANT OR LEAD AGENCY: <br />City of San Leandro _ <br />• PCZ,��',' ��e� 4 r,{.�! ��P ���f'".,.i.�..- 4 rtl�'�� r"-._; <br />Development Services Department -' <br />835 East 14th Street <br />FILING NO. <br />San Leandro CA 94577 <br />CLERK'S <br />CLASSIFICATION OF ENVIRONMENTAL DOCUMENT: USE ONLY <br />1. NOTICE OF EXEMPTION/STATEMENT OF EXEMPTION PLU 117 <br />[ ] A - STATUTORILY OR CATEGORICALLY EXEMPT <br />$25.00 (Twenty-five Dollars) - CLERK'S FEE <br />[ ] B - DE MINIMUS IMPACT - CERTIFICATE OF FEE EXEMPTION REQUIRED PLU 117 <br />$25.00 (Twenty-five Dollars) - CLERK'S FEE <br />2. NOTICE OF DETERMINATION - FEE REQUIRED PLU 116 <br />[ ] A - NEGATIVE DECLARATION <br />$1,250.00 (Twelve Hundred Fifty Dollars) - <br />STATE FILING FEE <br />$25.00 (Twenty-five Dollars) - CLERK'S FEE <br />[ ] B - ENVIRONMENTAL IMPACT REPORT PLU 115 <br />$850.00 (Eight Hundred Fifty Dollars) - STATE <br />FILING FEE <br />$25.00 (Twenty-five Dollars) - CLERKS FEE <br />3. [X] OTHER (Specify) Notice of Determination w/ De Minimis Impact PLU 117 <br />$25.00 (Twenty-five Dollars) - CLERK'S FEE <br />*THIS FORM MUST BE COMPLETED AND SUBMITTED WITH ALL ENVIRONMENTAL DOCUMENTS FILED WITH <br />THE ALAMEDA COUNTY CLERK'S OFFICE. <br />FOUR COPIES OF ALL NECESSARY DOCUMENTATION ARE REQUIRED FOR FILING PURPOSES. <br />APPLICABLE FEES MUST BE PAID AT THE TIME OF FILING AN ENVIRONMENTAL DOCUMENT WITH THE <br />ALAMEDA COUNTY CLERK'S OFFICE. <br />MAKE CHECK PAYABLE TO: ALAMEDA COUNTY CLERK <br />Rev. 1/15/91-1056C <br />d:\forms\cega\filing.cvr <br />