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EVALUATION FOR <br />AGENCY USE ONLY <br />In addition, an existing overhead power line will need to be relocated to <br />accommodate the new clinic. <br />C. SIGNATURE <br />The above answers are true and complete to the best of my knowledge. I <br />understand that the lead agency is relying on them to make its decision. <br />Signature: <br />Applicant Representative <br />Name of signee: C69112 <br />Position and Agency/Organization: Jam% O G cy-�E Sv Co c u ' <br />Date submitted: Ap(ztL-yo , 2016 <br />Environmental Checklist — Providence Regional Medical Center Everett — North Site Page 32 <br />© SHOCKEY <br />