subdivisiion preliminary stage application N
m�a 4
`' it��
Preliminary ,stege Revised App l 2010
JUL '13 2016
"rovw'4 OF
E � �� /i i ReviewApplication
qkjEME PROCESS,
1) Required Pre- uubrruisai;ern meeting with staff to determine general completeness to be held) no
than Ieek_pfir toeedl Iris 'I„dey., Cell ( ) 7611-1320'foran eppeintmient
) Submittal of complete appllnatlom "I original and '14 copies of the application package by monthly
deadline,
Determination of application; corrrnpleteneaa, All necessary information must be provided and
appropriate fee(s), paid for consideration for placement on, an agenda for that month.
) Incomplete applications will not, be considered for placement on any agenda until all rnissirn
Information hes been submitted.
) Planning Board meeting, generally the third & fourth Tuesday of,each month. You will be advised in
writing as to,'which Meeting to attend.
�) Following the meeting you will be provided with e copy of the resolution stating the Board's decision
on your application. if your application was denied your project cannot proceed as submitted,
DOCUMENTATION REQUIREMENTS:
1), Please submit 1 Ori inall & 114 copies ofthe completed application package to include'.
u ompleted .Appl tiio n signed & ducted
lire- uJ bmiaslon Meeting Notes signed by staff
Cqpy f meed: t
Sury
Fee: „ fin
ZONING STAFF & CONTACT INFORM,ATION:
• Craig Brown!, Zoning Administrator prai b n burr ,ne
• Laura Moore, Land Use Planner lm1oo,reQquueernsbuurV.net
• Pairrn Whiting, Office Specialist 118-761-82.20 pgmwagueensbuEy.net
Visit our website at www.queen sbiury,net for further informatiorn and forms
Town of Queensbury Pn nn4n, Deis- 742 & y Road- 0warn bury,NY y M4 , 578-761-8220 0
Prelfinjinary Stlgs evil ed AiP ril 2010
,
gg,.n2ral Information
Tax PaFcel ID Number 240-91-1-8, J t'J I '13, 2 D 16P
Zoning District., INC T(")'YVN C)F (.JU[�.F_-N,SBUIRY
AU@JJ&,@ _n_ Stage check onet-,
Skelich Plan Stace
Preliminary Stage X
Final Stage
Indicate thg fg,Uq4% jljg-,
Number of lolls proposed TWO
Residential or Commercial COMMrMCML
Total Lot acreage 4148
Proposed lbi sizes, 1.004 A 3.144
Prof,ect location RT IL&CLEVERDALE ROAD,
Devail"ed Description of Project [include current&proposedl usel:
Proposed two lot subdivision. current Cleverda,le store and Davies Davies Real Estate office-
/'k
Appillicant Name.- iress-
Me!ghan asad PO Box 307 Cleverdale NY
Home Phone cellD;
518480-1732
Work Phone Fax
E-Mail:
,Agent's Name. Address]
Van Du sen& Steves 169 Haviland Road
Home IPhone Cell.
Work Phone Fax
516-792-84'74 518-792-8511
E-mail
Owner's 9-ami. Address
Same as Applicant
Home Phone Fell
Wo,r k Ph o,n e Rax
E-mai I I
TovAi ofQue�enswjiry Pl,,innfng Office- 742 Say Road Queensbury, NY 12804 518-75'1-@220
P relli,minary St i9e Revised! April 20 1 O
ITEMS TO BEIDENTIFIED BY STAFF DURING PRE-SUBMISSION MEETING- You should use this: page for
guidance when drafting your applicatibri, how ever. i�l vffi be completed by a staff member, SubmMal of a preliminary
plat depicting existing and proposed conditions shall include the items as, noted below. Failure to induce all required.
information nia'-,;result in a determination of incomplieteriess and a delay in the processing of your application,
§A-183-113. Plat details and requirements.
The applicant is required tosubmit one (11 ofiginal and 14 cogles of the preliminary plat application. Such,application
shall inClUde the,following CIOCUnaents andior information:
A. EULKINARY PLATT Tlie preliminary plat shall be laid out by ai licensed professional engineer and!or a
licensed professional land suf-ieyor with a property, executed Ne4w York StWe Education Department
Exemption N. Such preliminary plat.shall be prepared at a scale of one inch equals 50 feet Zero inches, clearly
showing:
1) The location of all existing and proposed properly lines, buildings. a.valercoffses and other important
topographic features,
2) Existing and proposed contours shawing elevations at N00400t COMOUF intervals and extending at least
100 feet off ske,
1) The 1,:,caficn, names and wilffis of all existing and proposed' streets, easements, lets and building lin,",
well's and septio tanks andfields and siniflar facts regarding property hil mediate ly adjacent or opposite,the
proposed subdivision.
4) A location iniap showing,
(a)The zoning district or districts ltiiwhich the land to be subdivided is located- and
(b), Thee property included in the proposed subidivision and all contiguGLIS properties of the proposed,
subdivision and all properties within, 6,00 feet in: each direcfion from, One boundary, line of the proposed
subdi'visio,ji along any MlfigLlDus street or hich%vay. All properties shall be identOied by lot and parcel
number and names of owners-
6) The location and size of any exisfing sewers, water maims. culverts and drain pipes. electric. te[ephone
and cable television, lines and proposed sezers. vraiter mawvs, culverts andi drain pipes on the property, or
inirnediately adjacent to the property to be subdi'vided,
6) The proposed arrangement and approximate area.- width and length of street frontage and sethiack
requiraments:of each lot for,the purpose of demonstrating to the Planning Board that the proposed [Ocation
of:streets makes possible a layout of lots in accordance -&ilh the requirements of the Town, of Queensbuiry
Zoning Lard,16r the district or districts in;Pihi ch the subdivision is located-
7) AH parcels of kind proposed to be dedicated:to the public use.
8) The date, North arrow and,scale.
9) The title under Mich the proplosad subdivision is to be recorded, with 1he names of, the owner and lbs
engineer or land surveyor who, prepared the prefiminafy plat; the license number and sea] of the engineer
or land surveyor shall be affixed to the draw,ing,
B. JjAXQMjEL,ANS, Layout plains shall be prepared by a professional licensed enginearorprofessional licensed,
land surveyor with a properly executed New York State Education Department Exemption N. Suoh layout
plans smell be incorporated on the preliminary plat and shall show the following:
"I a
The exact layoQt and dimensions of proposed streets, inclvding st;Mioni'N and fie,in, to the c�nt r-line
distances of existing streets with monumvits aind other points, as required.
Town cif 0u!m,enswry Plaoning Offlre- 742 Bay Ra8d -Qu"ilsbkq, NY 128,04 , -318-731-8220, 2
Preliminary Stage Revised April 20 10
2) The Vocation and veWths of all streets, curbs, side-calks, easements, parks and other open
Spaces,
3) The proposed names of all streets, and the radii of all cur.iles in the street line,
4) The 101cation,of all proposed utilities. including the proposed veater supply, sanitary sewers,storm water
drainage system and any other proposed underground utilities-
6) Proposed lot hines.
6)
Thai date, North arrovand stalle,,
7) The We under which the proposed Subdivision is to be recorded, Mth the names of the owner,and
engineer or land sunieyor who prepared the Iay. out plans;the ficense numb is r and sea]of th e, an giflieeT or
land surveyor sha 11 be affixed to the drawing,
C. QQUjjUUL-T.1QN DETAILS-Construction details shall be prepared bya licensed proftzs,sionali engineer or a
licensedd,professional land surveyor,with a properly executed New York State Education Department
Ex,,,mipffon N. Such details shall include:
1) The proposed sanitary se-Per system, including pipe sizes, bedding and profiles.
2) The proposed storm, drainage system, including pipe sizes., bedding, catch basin and manhole details.
profiles and method�of&sposai of cicilb?c;ted stormwater,
3) The proposed-otitersupply system.
4)
Any other proposed underground Utilities.
5) A
typical crass section of the road%uay, including the right-of--vay width, pavement vJdth and depth all
pavement materials and subbase, the location of utilities- character and dimensions of cuurbs and
sidevealks:and side slope grading-
s) Profiles, sho-:ming the original ground surface and finished street surface at canter lines of afi streets,
percentage of grades of sveet% stal6ning, and elevations of all points, of CILDNature, points of intersection.
points of tangency and of proposed siewers, drainz, culverts. manholes and other features, Invert
elev-,)Wne and Mapes of sewers and drains and both surface and invert qlavations of nianhiall,as shall be
indicated. Proffles, shaH be drawn to the scale of four feet to the inch vertical and 40 feet to the inch
horizontal., The stationing shall show accurate center-line distances. The elevations of the ciAgirkal 'W
Wound
surface shall be to the nearest tenth of a foot and of fixed,paints to the nearest hundredth of a foot-
7) The l"ati,on and elevation of all proposed monument locabons.
8) The date and scale,
9)
The title under which the proposed sobdivisioo is to be recorded, with, the names of the o:,.vner and
en,gineer who prepared the construction details,- the license numblar and seal of the engineer shall' be
affixed to,the dravulng.
E)� LQ:§gaEE el,jIN. A landscape plan shali be prepared by a licensed tands,cape architect for subdivisions,
greater than I G lots. Such landscape plan shall lniclude:
1) The location and species of street trees, if retained xithin the right-of-nay,or proposed to he planted by,the
subdivider.
2) Details of methods of tree protection and VGO PlOrnfinig-
Town of Queensbury Planning Office, '7,42 Bay Road -OueelisiOury, NY 12804- 5118-7'51-8,220 3
PrelimJn ary Stage Revised April 2010
3) Plans. and details of aany site improvements related to park or recreation, ;planning;, inchiding liyout,
grading, planting and details of any iniproveimAnts.
4) Plans and detail's of inv,other public amenities prooided in:the subdivision.,
5) The dale and se-ale.
6) The title number which the proposed s0division is to be recorded, with the naimes of the owner and
landscape architect-who prepared the landscape plan: the license number and seal of the land'scople archiw:�v
shall be affixed to fte dra%-ving.
E, r.LL6SIUa.ELAU, A clearing pllanshall be prepared at a scale, of one inch equals 50 feet zero inches- Such
plan shall show the following details:
1i Existing vegewtion prior to,any clearing of Uae site for site investigadon purposes.
21 Areas of vegetation,removed from the site for investigation purposes.
3): The location of roadWaYS. Underground or overhead utilities not in roadways. fimilts of grading, proposed
location of any buildings., sepOr. systems, iv,-ells and driveways and any other improvements which, might
require
4), Areas where,slopes,, are greater than 20%, is per§A 83-2631-
55) Limits of proposed clearing of trees.
6�) Measures to,be talken to protect reniairiin,g trees.including details-
F. GB�QlNra A A TI
gjrj�di g plan and erosion control plan shall be prepared at a
scale of one inch equals 50 feet zero inches. Suich plan shall show the follcrMrig-,
11 A generalized grading and drainage plan ,does not require, spot grade s or slope designation).
2) Any phasing of tree removal anchor constroiWon-
G, EUYIIEQUMLNIA,L BECOFa- A long einvironiffienU assessment form shall be prepared in accordance with
theState Environmental Cluality Review Act describing the potential environmental impact of Uie proposed
subdivision.
H, STAT EMENT OF INTENT,. A statenient of intent shall be submitted by the applicant Sur�h Statement shall
include:
1) Proof of avinership of the kind to be subdivided, in forni approved by the Town Attorney,,
2) The nature and extent of proposed street improvements-
34 The nature and extent of any recreational features, parks, playgrovridsm water supply, sewerage and
drainage rights-of-way and easements, retendon basins aiid other land to be dedicated to public use and the
conditions under which,dedication of these features is to be made to the Town.
4) A statenient that this applicant will install al[ improvements in accordance with the standards prescribed by
the departments of the Tcrom having jurisdiction, and set alll monuments as shwron on the finial, plat thereof in
such maniner as the Board may designate-
1. A STORMWATER MANAGEMENT PLAN and a ST0,8MV&jB PQLILUTION PREVENTION PL
consistentwith the requirements of Chapter 147, Storniziater klanagement.
Town of Queens')up/F"I'anning Office- 742 6,V Road - aaeei,W)ury: NY x2804. 518-761-8222 4
Preliminary ary Stage Revised Aprll 2010
J.
1) The application for prelhrnninary plat approval shnalll be accompanied by a fee listed on the current scheduler
of fevers for the To m oafOueernsl ,uryw posted ki the Planning Office.
2) In addition to the fee listed on, the schedule of fees, thoe Planniing Bo3rd miry Charge e fee to developers of
projects requiring legal and technical re-view, provldledl that the fees charged, reffects the actual cost of the legal
and Wechnicai assistanice to the Planning, Soard.
WAIVER& if the Planning Board finds that an, of the information rsrpuiremnerrts as set forth above are
inappropriate Of not necessary to conduct ,an iinf rnnedl review, it nnay waive such information rgpuirermernts as
it deems, appropriate. Any such .waiver shnallll be rargde in writhing, and shall contain statements af'the reasons
Why the waived ianfom iatimn, requirements are not necessary'for• an informed review under the circumstances-
The Planning Board may grant such n aiyers on its own initiative or at the writ en re-quest that sets forth the
specific requirememis that are requested to be ,vaived and the reasons for they requested v.a mer) of an
applicant.
A183-14. Sol,)rni sion and Review procedure— S ubdivisIon Sl"gin Posting i equirernernts
D_ Notice. The subdivider shall display prominently on,the subject property„ for °10 days preceding; the date of the
pin blic hearing, at least one sign, two filer by,three feet in size: and carrying a legend prescribed by tfne Town
Planning, Beard,, announcing the pubfic hearing. The sign shall be io foll pu'bk view from the street pavement
and shall he legible from, the street.if the property is bounded by more than one .street, a sign shaft be placed
on each struied that bounds the property.
Town of Queensbtiry rannir*,g Office- 742 Bay Road - uweensbury, NY 12804, 618-761-8220 20 5
Preliminary Stage Revised April 2010
Pre-Subinission Conference Form
I.. fax Map I'D: 240-9�1-8
2. Zonhiq Ciassification: NC
3'. Reason for:Revjeiw, S,ubdivision
4, Ordinance Section,
6. Pre-Submission Meiebng Notes: Outstanding Re s,Tio Be Addressed Include:
1 Dead ,/Yes _ No
2- General Information YesNo
3 preho'libary Plat Yes No
4. Layout Plans Yes No
Coi:stnjcflon Detziils Yes No
6Landscape Pllan #Yes No
7. Clewing Plan Yes N0
& Griding & Evosion[ControlYes No
9, Enivironmental Roport yes No
10. Statemient of intent 1"des No
ill, $wrmwater Plan!SWPPPYes No
12. Feez 21 Yes No
13. Waivers Yes No
1A, Subdivision Sign Posting Yes NO
15. Signature Page pe Yes No
Ll k"9 2patec'.", L61
4L 1TA -SL)a042 Ll
6
Staff Representative: LL Min)
Applic;ant i Agent,,
Date:
Tovial of Queensburi Planning Office. 742 Bay Road Queensbury, NY 12204 518-761-8220 6
617.20
Appen&r A
State Environmental QuaI4, Review
Full En vironmental Assessinew F-orm
Purpose. The 'pull 'Environmental Assessmeat Forrn (EAI')provides an orderly and
comprehensive means for evaluating, the potential environmental significance ofa,proposed
action. The qijestion of whether an action may be significant is,not always easy,to answer.
Frequently, there are aspects of a project that are subjective or unmtasulrable. It is also
understood that those who determine significance may have 14tt[e or no forynal knowledge oaf the
environment or may not be:technically expert in environmental analysis. Inaddition, many who
have knowledge in,one particular area may not,be aware of the broader concerns,affecting the
question of significance. The lead agenoy must use:the Full W for Type I actions and may use
it for Unlisted actions,
The Full EA F consists of three parts and when completed it will serve as the determination of'
significance:
Part I -Is cornpleted by the project sponsor. Part I provides basic information including a
description of the proposed action,proposed site locationand its environmental resources. The
information provided in Part 'l is later used by the reviewing agency to com plete Parts 2 and 3.
The questions in Part I are grouped in sections A-G-
Section A gathers information that identifies the projectsponsor, the proposed action, and the
proposed action's location.
Section B requests, information about government approvals,or funding.
• Section C requests, information.about planning,zoning and community,services..
Section D requests information about the proposed action.
Section E requests information about resources on or adjacent to the proposed site.
Section F provides the project sponsor the opportunity for supplying additional information
including project elements that may avoid or reduce impatts.
SectionG is where the certifying signature of the prepareris provided.
Part 2 - Is counpleted by the lead agency. Part 2 is designed,to help the lead agency inventory all
potential resources,that could be affected by a proposed action and to determine the potential size
of the impact by, providing a series of questions that can be answered using,the information
found in Part L To further assist the lead agency in completing Part 2, the form identifies the
most relevant questions in Part I that will provide the information needed toanswer the Part 2
question. Part 2 is designed to help a reviewer ident4 any element of a proposed project that
may have a potentially significant adverse impact on, the environment.
Part 3 -Is completed by the lead agency,, Part 2 questions where the impact has been identified
,as potentially moderate to large or where there isa.need to eKplain why a particular element of
the proposed action will] not, or may, result in a significant adverse en v iron rnental impact should
be explored in a series of w�ritten, well reasoned staternents-in Part . The discussion of impacts
in Part 3 will serve as the supporting doeurnentation for the determination of significance.
Fidt E,n vii-onmental Assessment Foiwi
Part ] -Projecs and Selling
lnstrucfions for Completing Pw-t I
Part.1 is to eompletetl by the applicant or project sponsor. Responses becotne part of the application for approva I Gr funding,
are subject to public review,and may be subject to further verificat[on,
Complete Part I based on information curTently available. If additional research or investigation would be needed to fully respond lo
any itern,please answer as thoroughly as possible based on curreril information, indicate wlwthar missing information does not oxist,
or,is not reasonably,available to the sponsor;and,when possible,generally de ripe workor studies which would be,necessary to
update or fully develop that infbrmztion_
ApphiNarilsisponsors must compteto all items in Sections A,&B. In Sections C,D&E,,most items contain an kitial question that
must be answered either"Yes"'or Iffloe answer toa the initial question is"Yes",complete the sub-questions,that follow. Ifthe
angwer to the initial question is"No",proceed to the next question. 8 ection F a[lows the project sponsor to identify and anach any
additional information. Section G requires the name and signature of the project sponsor to,verify that the information,contained in
Part I is accurate and complete,
A.Project and Sponsor Information.
Name of Action or Project:
Proposed Subdivision
Project Location(describe,and attach a general location map)-:
Rt, 9L& Clleverdaille Road
Brief Description of Proposed Action(inclu&purpose or rated'
Propose�d to lot commercial subdivision. Br8ak exisfin�g real estate office from existing store..
Name of App]loant/Sponsor: Telephone' 518-48,01-11732
I Megtan esari
Address-.
PO B,ox 307
city " state: Zip boder
Cleverdale NY 128 0
Prr�ect Contact(if not Same as sponsor;give name and fitlefrole): Telephone:
Address„
Ckylpo: State: Zip Code:
Property Owner (if not same as sponsor'),: Telephone-,
E-mail.
Address-
Citylpoz state.; Zip Code;
P�age I of 13
8,GovernmEnt Approvals
119.a;-
vernment Approvals Funding,or ,Spunsorship, (LLr.lgnd'ung` include5grant5, loans,tax relief,and any other forms,of finaricial
assistance)
Government Entity If Yes: I dentify Agency and Approval(s) Application Date
)Required (Actual or projected)
a, City Council,Town.Board,, 11 Yes 13 No
or Villa e Board of Truslees
b, City,Town orMllage C Yes 0 No
Planning Board or Commission Planning Board - Subdivisilon
c.City Council,Town or 0 Yes o No,
Village ZoningBoard of Appeals Zoning Board -Variama
d,Other local agencies 11 Yes El No
e.Cornu ntyagencies 11 Yes 01 No
I.Regional agencies 0 Yes 12 No
&State agencies 0 Yes 11 No
.h.Federal apilcies cl Yes o No
i, Coastal Resources.
i. Is the project,spite within a Coastal Area,or the waterfront.area of a Designated Inland Wattrway? 0 'Yes 0'No
If Yes,
U- Is the project site located,inatornmunit y with an approved Local Waterfroint Revitalisation Program? 0 Yes,11 No
Ui. Is the project site whbin a Coasta]Erosion Hazard Area? 10 Yes O'NG
C.Planning and Zoning,
C.I.Plarnling and zorting actions.,
''Fill administrative or legislative adoption,or amendnient of a Plan,,]IDGal law,ordinance,rule or regulation be the 10 'es, Flo
mtd actions to proiceed?
only approva I(s)which must be granted to enable the prop I
a If Yes,complete sectio�ns,C,F and G.
as if No,proceed to question C,2 and complete all remaining sections an,id questions in Part I
C.Z.Adopted land use plans.
a.Do any municipally-adopted (,city,town,vil[age or county)comprehensive land use plan(s)include the site s 0 No
where the prqpolsed action,would be [olcmed?
I f Yes,does the comprehensive plan inc[ilde specific recom m endations 1br Ole site where the proposed aftion 10 yes,4lo
would be located?
In_Is the site of theroposed action within any local or regional special planning district(for example: G , y 11 Ye
e: reen00% N
p SA o
Brow nfield Opportun ity Area(BOA)�; designated State or Federal heri tage area,watershed manapmient plan;
or other)
If Yes,idienti f
y the plan(s).
c. Is,the:proposed action located wholly or partially within an area listed in-in adopted,municipal open space plan, El Yes)(No
or ail adopted municiplat firmland protection pitan?
IfYes,identify the p1ali(s);
Page 2 of 13
C3. Zoning
a,, is the Site of the proposed action located in a rnuniiJ pal 4 with an,adopted zoning law or ordinance. -NI-Yes 11 No
IfYe5,wha any applicable over]a,y district?
b., Is,the use permitted or allowed by a special or conditional use permit? es cl No
0.Is a Zoning change requested as part of the proposed aoflon? 0 Yes 4<0
If Yes,
i. What is the proposed new zoning for the site?
CA Existing,corninunity services..
a.In what sc'h o ol district is flue project site located? Lak,m Gow9e
b,What,police or other public protectiort forces serve the project site?
Warren County
c.Which fire Protection and emergency medical services serve the project site?
North Queensbury
d at parks serve the project site
D.Project Details
DA.Proposed and ROU-nitial Revelopment
a,What is the general nature of the proposed action (e.g,residential,industcreatilonal; ii'rn Ned, inol ude a]I
Components)? Q 1– 0—!
b, a�Total acreage of the site of the proposed action? 4,IQ acres
b.Total acreage to be physically disturbed? 0 acres
a.Total acreage(project site and any con tiguou 9 properties)own ed
or f onTrol led by the applicant or project sponsor?' 4.148 acus
Q,Is the proposed action an expansion of an existing project or o se? EF YLKN,
t If Yes,what is the approximate percentage of the proposed expansion and idrentify the units(e.g-,acres,miles,housing units,
Square fect)? % Units.-,
d,Is the proposed action a subdivision,or does it include a subdi'vislon? Kyes 11 No
If Yes,
L Purpose or type of subdivision?(e.g,residential,industrial,Commercial,;,if Mixed,specify types)
Commerdal
E Is a clustedcorumation layout;proposed? 11 Yes a No,
ffl. Number of lots proposed 2
iv, Minirnuin and maximum proposed lot sizeO Mittirourn 1,0014 maxinjun, -144
e,Will proposed action be constructed in multiple phase'? YCO(NO
L If No,,anticipated pedbd of construction, months,
ff. If Yes'.
"Total num, ber of phases anticipated
Anticipated 00mrnenicement date of phase I (including demolition) month year
Andelpated completion date of final phase month ___year
0 Genera Hy describe connections or relationships among phases,including any contingencieswhere progress of one phase
deter mine tier hig or duration of future phases.
Page 3 of 13
project include ne.ww residents
f�Does the � al uses 0 Yes 01
If Yes,show nurmbers o;funiis proposed„
j " . LM Etn q EAR,uN Multipt Parmil fiiur rar
Initial phase
At completion
of all phases
S.Does the proposed actions include new mom-residential construction(including expansions)? 0 Yes 11io1
If Yes"
t.Total rtuu'nber°of structures
af. Dimensions(in feet)of largest proposed structure,: __height„ ��"m�ltit,: and l ng
r'ir. Approximate extent of building space tray be heatedtui cooled squiare fMet
by byes the proposed action include consttmuctlon air other activid s that will result in the impoundment of any 12 "esrb'
liquids,such as creation of a water supply,reservoir,'pond,lake, waste lagoon or oilier storage'?'
If Yes,
i" p°urpose of the iunpoundrrtent:::
k If a water impoundment,the principal source of the water: 0 Ground water 10; u-rface water streams ®i tither specify:
W. If other than water,idents die type of impoundewc;lGined liquidsand their source..
iv. Approximate size:of the proposed impoundment. Volum„ne; m111ion gallons,;,surface area; �. arses
v. Ditnensions ofthe proposed darn or impounding structure, heighnt„ _ length
vi. Construction mnetho&matena1s for the proposed dada or impounding structure(e.g.,earth full,rock,,wood,concrete):
D.2. ProjectOperations
a,Does the proposed action include any excavation,miming,or dredging,during construction,operations,or both9 Y_.Xlq0
(lot including gencrai site preparation,grading or installation of ufllities or foundations where;all excavated
rn;aterialls will remain onsite),
If Yes:
t-What is the purpose of the excavation or dredging?
iE How's much tnateriail(includingrock,earth,sedlrnents,etc)is proposed to be removed frorn the site"
Volume dearunios es tom -or cubic yards);
overn of ti=7'
ifr Describe,nature and charancteristios of materials to be excavated or dredged,and plans lo use,manage or dispose of therm,
iV. the s be be dewatering or processing of excavated materials?errals? _ 0 des 11<10
Wie.
he total area
v- What is t� � t�be,dredged or excavated? _.._� aures
..........
vi. What is the maxim um area to be worked at any one time"? acres
ver, Whr<at wwouid be.thv rnaxirnutnr depth ofexcavatiorn or dredging'"? feel
vid. Will the excavation require blasting? ct Y'es/<" o
U. Summari7A site reclamation goals and plan:
b,Would the proposed action cause or result in altervadon of;,increase Or decrease um size of,or encroachment 0 YesXN10
into any existing vwedatnd,wwaterbody,shoreline,beach or adjacent area?
If Yds:
i. Identihy the wwedand or wwaterbody^which would,be affected(by name,,vwater,index.number,wr-etland map number or geographic
description):
Page 4 of 13,
a''
i. Describe how the proposed action w ouuld affect that wvaterbody or wiretiand,e.g. excavation, fill,placement of structures,or
alliteration of channels,ban and shorelines. Indicate extent of activities,alterations and additions in s,quuare feel oracres;
lar1 Will
pIf r proposed cause or res.uult in distturbance tbottombottosedirnents"�
p
iv. We
ilproposed,osed aet:iiom cause or result in the destruuction or removal of awquuatic vLgetatibn? � es q"
IF
area of vegetation proposed to be removed �.
■
expected acreage of aquatic vegetation reumainIng after project cornpliction
purpose ofproposed removal(e.g.beach clearing,invasive species control,boat aecess)°
proposed method of plant removal
1P if chenuicalPherbicide treatment wwiiil be used,specify product(s);
v, Describe any proposed reciarnation/mitigation fol lowing di,stuurbance
c.WilI the pro3pnsed action.use,or oreate a new demand for water? ❑ des XNn
lf"�es;
I Total anticipated water uasa, ,eidemand per d4y gallonsiday
U_ WilI the proposed action obtain water from,an existing,puubli!c water supply? 0, YespQ41e1
If Yes:
0 Maine of district or service area.;
Does the existing public water supply have capacity to serve the proposal':? 12 Yes El No
Is the project,site in the existing district? 0 Yes 0 No
Is expansion ot'the:disli ict needed' El '"byes til No
0 Do existing Innes serve the project site? 0 Yees F No
irr. Will line extension within an existing district be necessary to supply the project? ❑ Yes❑No
Qf. es:
• Describe extensions or capacity expansions proposed to serve this,projecr
• Source(s)of supply for the di:strict:,
iv, is a new water sup; ly district or service area proposed to be formcd to serve the project site? 0 "'uses
If Yes=
ApplicanUsponsor for new district.
Date application submitted oranticipated:
Proposed source(s)of s-supply for new disHcit.
ua if public water supply will not,be used,describe planus to provide water supply for the project:
vi.Ifww'ater;supply will be from walls(public or private),maximuurn puumping capacirT. gallons/minute.
d_WilI the pw posed action generate Iiquuid wastes? M Yes o
IfY s:
i.
Total anticipated liquidwaste generation Per dal _ ,, gallonsMawy
V.Natuxe ref liq uid was ms t be generated(e,,i sanitary wastewater,industrial,ificombination,describe all components and.
approximate volumes or proportions of each); _
lar. Willthe proposed action uusie any existing public wastewater treatment:faciRiles? ❑ Yes,Vo
If
• Name of wastewater treatrm ent plant to bie used:
• Name of district.
• Does the eXisting wastewater treatment plant have capacity to serve the project's 10,Yes❑No
• Is the project,site in the"Mrig d istrlct? ❑i Yes is No
Is expansion of the district needed? ®i Yes 13 No
Page 5 Of 13,
lu. WIN
the proposed ac on generate or emit rncthane(including,but not limited to,sewage treatment plants, e 01
landfills,composting facilities?
If Yes„,
is Estimate methane generation in tonsfyear(rnetric)_
fr.Describe any methane capture,control'or elimination measures included in project design�co,go,a combustion to generate Beat or
electricity,flaring)-
i,'lvma+'ill the:proposed action result in lbe release of Mr Pollutants f'rorn rrpen-air,operations air processes,such as 0 yes>tllo ..
quarry or],and fill operations'?
ff' tm.Describe operations and nature ofemissions diesel exhaust,rock particulatesldwst)m
I
J.Wil:I the proposed action result in a substantial increase in traffic above present levels or generate substantial 0 y 0
new demand for sprrtatirun facilities or services?
lf' "es;:
f:. When is the peals traffic expected(Check all that apply). El(Morning 12 Evening O eekend
Randomly between hours of to
H.,For commercial activities only,projected nmurnber of semi-trailer trunk trips/day-
M,Parking spaces; Fisting Proposed Net inereasefde reale
ay.(Ghees the proposed action include any shared use parking? Ll Yes,13 No
v, I f the proposed action includes any nwadihcation oFexisting roads,creation of ivew roads or change In existing access, describe;
W.. Are public/private transportation service(s),ra;r facilities available within 1/2 mile of the proposed site? tai Yes 0 No
rice ''tiuiill the proposed action include access to public transpertatlon or ac sumo od'ations for use ofluybridi,electric 0 Yes 11 No
or other alternative fueled vehicles?
Mi.Will the propQsed action include,plaits for pedestrian Orr bicycle accommodations for connections to existing 0 Yes❑No
pedestrian or bieycle umtes,7
k. Wi
ll 7p sed action foir commercial or industrial projects cunly)generate neer or additional demand � ' 0
If Yes.
i. Estimate annual electricity demand during,operation of the proposed action-
U. Anticipated sources/suppliers ofele tricity for the project(e.g.,On-site combustion,on-site renewable,via grid/(
local utility,Or
other)..
lfi. W Al the proposed action rewire a new,or, upgrade tO,L an existing substation? 0 Yes cl No,
1.Hours of Operation. Answer all hornswhich apply,
s. DuringConstruction: U. During Operations.,
Monday-Friday-Monday Friday'
,._._ mm,
5atttrrtla� '�aCnrrrlay;
Sunday- Sunday!
Holidays; Holidays-
Page 7 of 1
s.Does the proposed action include construction or modification of a solid waste management facility? 12 Yes"ZZ0
If Yes;
i, Type of 4ninagernent or handling,ofwasic proposed for the site(e.g,recycling or transfer smflon,,composling,landfill,wor
other disposal activiti es,)-
ii- Anticipated rate of'disposal1processing,
Tons/rntnth,if transfer or other non-cornbustionAhermal treatment,or
Tons/hour,,ircombustion or thtrrnal treatment
W. If land fi 11,an I icipated site life; years
t.Will proposed action at the site involve the commercial generation,treatment,storage,air disposal,of hazardous 13 YaTNINIG
Waste?
Iffes:
i. amc(s)o F all h=rdouswastes ar constituents to'be generated.,handled or managed iat facil ity,
H.. General ly describe processes or activities,un. [ng 17azardous wastes or constituents,
W. Specify amount to be handled or generaW tons1mondl,
iv. DLstribe any proposals for ort-site minimi zation, recycling or reuse of hazardous constituents:
v. Will any hazardous wastes be disposed at an existing offsite hazardous,waste facil4? 0 Yes 13 No
If Yes:provide name and loication of facility-.
If No-. describc proposed management of any hazardous wastes which will,not be sent to,at hazardous waste'foci Hty
E.Site a nd Setting of Proposed ActiGn
J. Land uses on and surrounding the project site
a-Existing,laad uses,
L Check all u5cs,thatuccur on:,,adjoining and near the project site.
* Urban 0 Industrial AWQpmmercialcsidential (subtirban) cl, Rural(nion-fann)
*
"It Forest 0 Agriculture T3 Aquaflic 10 0 Cher( Ps ecify)-,
it. lf.mixof uses.,generally describe.,
b-Land uses"and covenypies ort the project site.
Land use or Current Acreage:After Change
Covertype Acreagl_ (Acres 4-/-)
Road's,buildings,and other paved or impervious
surfaces .52 .52
--1- 0
Forested 1,.2;5 1,25 01
Meadows,,grasslands ds or brushlands(non-
8 3701
agricultural,including abandoned agricultural) 21.372. 8
Agricultural
(includes active:orf hards, eid,gT!Tbouse e of 0 0
Surface water features
flakes,ponds,streams,rivcrs,etc.) 01 0 01
ao Wetlands,(freshwater or tidal.) 0 0 0(
Non-Vegetated(bare rock,eatih or fill), 0 0 0
Other
Describe:
Pa d'9 or f 13
c,is the project site presently used by members Qfthe community far public:recreadon�
r- lt"Yes-explain:
lain:
d Are there any facilities serving children,the elderly,people with disabilities(e.g.,schools,hospitals,licensed Yes c
day care ceruters,or group horrtes)within 1500 feet of the project site?
If Yes,
t, ldentiffy Facilities:
e.Does the project site tonta:in,an existing*dam? - o
If ,es:
i. Dimensions of the dans and inwpoundrnea.-
V Dam height: feet
0 Darn.length;: feet
Surface area: acres
6 Volurne impounded: gal Ions OR.a,pere-feet
im`,Darn's existing hazard clas.s,illcatiow
iia: 1P'rovide elate and sum rnarize results oifflast inspection:
f.Has the project site ever been used as a municipal,commercial or industrial solid waste Management facility, 0 YeSAVO
or dates the project site adjoin property which is now.,or was at one tinte,used is a solid waste r anagernent,ffacili ?
If Yes:
4 Has the facility been formally closed? Yes a� No
0 If yes,cite sru esidocu.r entatica:.
r"i,Describe;the location of the project.site relative to the boundaries offtht snli;d waste rnana,gentent ffaoilitya
W. Describe any development constraints due to the prior solid waste activides:
g,Have hazardous wastes been,generated,treated andlor disposed of at the site,or does the project site adjoin 10
Ya&11tZ!0
property which is now or was at one time used to cornrnercial.lyr treat,store and/or dispose cfha7ar'daws waste?
IffYe&,
L Describe wwraste(s)handled and waste mwmana einent activities,including approxirrmate time when activities occurred..
h. potential contaminiatiorm history. Has there been s reportcd spill at the proposed project site,or have any C, yes.N;<N w
remedial actions been conducted at or adjacent to the proposed si
If Yes.:
Is any portion of the site Iisted on the IwtYSDEC' pi[is Incidents database or Environmental Site 0es,lNc
Remediation database? Check a,l]that apply.
Yes Spills Incidents database Provide DEC tel number(s):
Yes,—EovironmettaI Site Remediation database Provide DE ltd number(s):
0 Neither database
rry If site has been subject of.11CRA.corrective activities describe control rneasu;res:
UL Is the project,Within 2000 feet of any site in the NYSDEEnvironmental Site Remediation database? 0 Yes 1-1 No
If yes,provide DECIIS nuurnhe.r(s): mm
iv, 11 yes to(i),(H)or(iii)above,describe current slates offs1re(s);
v. Is the project site subject to ail,instftutjonaj control limiling property uses? 0 Y4.15 111<10
0 If yes,DEC site ED num ber.-,
0 Describe the type of institutionalcontrol deed,restriction or easement),
P Describe any use limitations:
0 Describe Muy era, incerirq control&:
0 Will the project affeal the institutional or wgincering controls in plate? 0 Yes 0 No
Explain:
E,2. Natural Resources On orNear Pinoject Site
a, What is the avemge depth to bedrock on,the project site? feet.
b,Are there bedrock outcroppi ngs on the proj cct site? 131 Yies4rlo
If Yes,what proportion of the site is comprised,of bledratk ou tcroppings?
0.Predom inant soil type(s)presen ton project site° %
d.What-i-3 the average depth to the water table onthe project site? Average: feet
a—Drain a-g–e-—status of piroject she soils,0, We]I Drained;
do %of site
0 Moderwaly Well Drained: %of site
13 Poorly Drained %of Site
f.Approximate proportion of proposed action site with slopes: to Il-10%; /(VC2_%ofsite
0 10-15%., %of site
0 15%orgrcaten of site
g-Are:th ere any unique geologic feaureg ion the project site?' 0 Yes`Azo
If Yes,desrribe.,
...............-
h.Surface water features.
i. Does any portion of the project site contain wetlandsor other wakerbodics(includingstTeams,rivers, 11
ponds or Lakes)?
fi,,. Do any wetlands or other waterbodi es adjoin the project si te'O' 11 'Yes 4KNO
If Yes to either i or H,continue. if o,,.skip tot-,,,21.
ift. Are any ref the wetlands or waterbodles within,or adjoining the project site regulated by any federal, 0 Yes ko
state or local ageney?
iv, For each ideritified wetland and watcrbody on the project site,provide the following information.
Streams: Name Classification
4P Lakes or Ponds.: Name Classification
0 Wedands. Name Approximate Size
Wetland No.(if regulated by DEQ)
V. Are any of tht above water bodies listed in the most recent compilation of water quality-impaired 0 Yeo
waterbodies?
If yes,name of impaired water bodythodies and basis for listing as im,paired:
L Is,the project site in a desip�ated,Floodway? 0 YesAI:No
J-Is.time project site:in the I GO year Floodplain? 13 yes*kNo
k.Is the,project site in the:5010 year' loodplai n? 0 yestNo
1.Is,the project sate located over,cir immediately adjoi n in g,a primary,principal or sale source aqfifer? Yes
Ifyes-
i.Name;of Aquifer:
if. Source of in66rrnation:
Page 11 of 13
. Identi thepredonuirnant wildlife species that occupy or use the project site,.
M
n,,,Does the project site contain a designated significant natural Community? a Yesgito
If Yes.
i. Describe the habitat/'community(composidoii,function,and basis fordesignation):!
ii, Source(s)of description or evaluation:
W. Extent of community/hiiltitat.
Currently: _ ._._� acres,
0 Following completion of project as proposed; acres
Gain or lass(i,ndicabte;+-or acres
.W.
�
o.does project site contain any species of plant or anmrnaI that is 9.isted by the federal government or NYS as 0 "` ess;to
endangered or threatened,ordoes it contain 4ny areas idenfiried as habitat for an endangered or th ate ned species?
If Yes
is Species and listing(endangered or threatened;).
if. Nature of use ofsite by The species.(e.g.,resident,seasanaA, transient),.
Does tits project site contain any species of Rant or animal
p• p J �''p A� that is 1`ust;ed by NS as rare,or as a species of e"%�o_
special concern?
3f Yes:
p, Species and.lusting;:
,r""_'Nature of use of Site by the specifies(e.g.,resident,seasonal,transient),
q.Is the:project site or adjoining area currently used torr hunting,trapping,fishing or shefi'fishing? 10 Yesk O
If yes„give a brief description of Incuws^the proposed action may affect that use°
S-3. Designated Public Resources On or Near Projgct Site
a.Is the project sine,or any portion of it,loeatedl in a designated agricultural dis[Tiot certified pursuant to 0 Yes 21V111
Agriculture and Markets.Lawv, Article 25-AA,Slecdon 303 and 304?
If Yes, provide:county plus district narnelnurnber
b.Are agricultural tatds consisting of highly productive souls present? rl d o
L If Yes.acreage(s)can project site
ii. Sour (s)of soil rating(s).
c Does the project site contain all or part of,or is it substantially contiguous to,,a registered National , 0 iio�No
Natural Landmark
I:f"a'm
i. Nature ofthe natural landmark: 1 :biological Community eologi:caA Feature
H. Provide brief description of laandin a;rk, inclu ding,values behind designation and auppmdmate:siaeleart ;rut:
d.Is the project site located in or does it adjoin a state listed Critical Envirroanrnental Area! o Y No
'if Yes:
L EA name:
fl.Basis for designation:
iir, 'Designating,agency and date;
Page I of 13
e.Does the project site contain,or is it substantially Contiguous to,a bui Id hig.,,archaeological site,or district yellt�0
which is,listed on,or has been noraffiated by alae NYS Board,of Historic Preservation for inclusion,on,the
State or National Register of Historic Places?
If Yes,
i,Nature ofhilstoriOatehaeological resource. OArchaeologj,aal Site 0 Historic Bui[ding Ot-District
U.,Narym
W, clef description ofattributes on which listing is base&
f.Is the project site,or any portion of it,located in or adjacent to an area designated as sensitive for 0 YesR,-No
archaeological sites Oil i:he'NY State Historic Preservation Office(SMFO)archaeological,site inventary?
g.Have additional arch awtogica,11 or historic sites)or resources been identified op the project site? C1 Yes"CIO
117yes;
L Describe possible resource(s),-
fi.Basis far identification:
h.Would the project site be visibic From any officially designated and publicly accessible federal,state,or local a Yes KNO
seenic or aesthetic resource?
If Yes:
i. Idunfifyrcsourcc.-
if, Nature of,ar basis for,designat[on, established bighway oveflook,state or local parlay state histoeic trail or seen ic byway,
etc.).
ffl, Distance:between project and resource, miles-
i. Is the project site located within a designated river corridor uhnder tI e W 1 Id,Scenic and,Reereat ional Rivers 0 Yes
Programa 6 NYCKK 6667
F. Identify the name of the river and,its designalion:
i i, is the activity consistent with&velopraent restrictions,contained in 6NY CRR Pad;666? 0! yes NO
F.,Additional Information
Attach any additional information which may be needed to clarify your project.
If you have identificdany adverse impacts which could,be associated with yow proposal,please describe those imp aCts pilus any
measures Which you propose to avoid or minimize them.
G. verifieaWro
I cerfif
,y that the information provided is true uayt be fray nowledge,
Appli=it/SpDate
Signature— Titk_
Page 13 of 1,3,
F ull Environinewal Assessmeyrt Foiwi
,PaH,2-Identification of Potendal'Project Impacts
Part 2,is to be com Pleteid by the lead agelley. Pan 2 is designed to help the lead agency inventory,all potential resources that could
be affiected fay a proposed project or action- We recognize that the lead agency's mviewerys)will notnecessarily be envirorimenial
professionals. So�,the questions,are designed to walk a reviewer thraugh the assessment process by providing a series of questilons,that
can be answered using the hi fhrmation round in Part 1. To further assist the lead,agency in completing Part 2,the form identifies the
most relevant questions in Part I that wi I I provide the in fbmnatlon needed*answer the Pan 2 question, When Part 2 is oompleted,the
lead apnoy will have identified the relevant environmental areas that may be impacted by the proposed activity.
If the lead agency is a state agency and the action is in any Coastal Area,,complete the Coastal Assessment Form before procceding,
with,this assessment.
Tips,for completing Part 2.-
6 1 Review all ofthe information provided in Pin I
0 Review any application,maps,supporting materials and the Fu I I EA-F Workbo6k.
a Answer each of the I B q uestions,in Part 2,
0 Ifyou anS;Wer"'ir'cs®'to,a numbered question,please complete all the questions that follow in that section.
P If you answer"No"to a numbered question,move on to the next numbered question.
Check appropriate column to indicate the anticipated size of the hnpact.
0 Proposed projects that wou Id,exceed a numeric threshold contained in a question shoifld,result in the reviewing,,agency
checking flie bo�x."Moderate to large linpact may war cur."
0 The reviewer is not expected to be an expert in environmental analysis.
Ifyou are not sure io,r undecided about the size of an impact, it rnay help to review the sub-questions for tile 9tneral
question and consult the workbook-
'When answering a question considerall corn.ponents of the proposed activity, that is,the"wholc action'.
Consider the possibility for long-term and cumulative impacts as well as,direct impacts,.
Answer the question in a reasonable manner consider1r,the scale and context o ro ect.
1. Impact on Land
Proposed action may involve construction o�n,or physkal alteration of, 11 NO E3 YES
the landsurface of the proposed site, (See Part 1.D.1),
-
"Yes anxvver questions a- "NO move on to Stchon 2.
clev ................................
ant o,or� Moderate
Part I small to large
Questian(s) impact impact ntay
may oceur occur
a.The proposed action may involve construction on land where depth to water table is B2d 0
less than 3 feet
b.The proposed action may involve construction on Slopes of 15%or greater. B2f 0 0
c.The proposed action may involve constmotilon on land where bedrock is exposed,or Eta, 01 13
generally'wi thin 5 feet of exisfing.gTpynd surface;
d Tb e proposed action may involve the excavation and removal of more than 1,0100,tons D2a 0 12
ofnaturat material.,
e.The proposed action may involve construction that continues for more than one year Die 13
or in multiple lames.
f,The proposed action may result in increased erosion,whether from physical Me,132q 0 12
disturbance or vegetation removal(including ft-orn treatment by herbicides),
&The proposed action is,or may be,located within a Coastal Erosion hazard area. Bl 0 0
h.Other impacts., a
Page I of 110
L Other impacts.
I
P Impact o.n grottndwater
The pr prased action mays result in n w or additional use of ground water, or 13 NO 0 YES
may have the potential to introdure contami nants to groond water or an ag0if&'
(See part 1.D.1a, D.' .p, t, ..d,D. .py D.2.q, D.2.t)
I ,Yes".r ansiver gve-sl ons a-h- jV"No", move an to Sectiion„5_
Relevrant No,or Moderate
Part I sanall to large
Qucsfio"(s) impact impact may
rrua
occur occur
a.Tile proposed action may requim new,water supply wells"or create additiDnal demand Me Ell �
on sypplies frons existing water supply we]Is.
b.Water supply demand from the proposed,action may exceed safe and sustainable lac a 0
wwoithdrawwral capacity rate of the local supply or aquifer.
CiteSource:
ce The proposed action may allow or result in residential uses in areas without water and D l a,Mic 0 0
sewer servwes.'
d,The proposedaction may include or require wastewater discharged to groundwater. 112d,1521 0 0
e.The proposed a,awti n:may result in the construction of water saa:pply we Us in lecaticns la c,Etf, n 0
where groiondwater is,or is suspected to be,contarmhated, El „E lh
f:The proposed.action may require the baulk storage of petroleum or cheinical products, D2,p,Eli 0 n
,over ground water or an aq !f"er.
g.The proposed action may involve the commercial application of pesticides within 900Ella,I)2q, is
feet of potable drinking water or irrigation sources, lel,0'-)'c
h. Other impacts: a n
. Impact on Flonoffln
The proposed action may result in,devre:loprnent on lands subject to floodin& 0 NO L1 y ES
( e,e Part 1: F-1)
Yens", 47nswwer questions a, . k"No"'" ar rve on to Section 6,
Relevant PMIo,or l�rideratc
Part
1 small to lar° c
Questions) lraa,pact irmpact may
rru:a occur occur
a.The proposed action may resaalt in development in a designated floo4ww^a . Eli n F1
b�ne pmposed actloa may result in development within a l 1001,Year floodplain E2J 0 n
eo The proposed aetiom may result in development within a 500 year floodplain. f 2k n
d
patterns., action may result in,or require,modification,modification,of existing drainage limb,D2e Et
pane
e..The proposed notion may change flood water flows that contribute to flcadim; ,. li b,E i,,, n 0
E2j ER
C if there is a damn lnc,ated on the site of the proposed action,the dam has£'ailed to meet Ele 0 n;
one or more:safe criteria on its most recent in ect:ion.
Page 3 of 10
g.10ther hnp,acrs:
. Impacts is n Air.
The proposed a,dion ruray include a state regulated air emiss,lon source. lel NO 13 YES
(See Part 1. DIX,D,2,:h, I.
ai "Iyes^", answeryeVions a-f If",N6„ apm veon fol Section t
Relevant No,or Moderate
Part I small to large
Question(s), impact Irnpra,et rarary
Enny occur oceur
a_If the proposed action requires fedcrs:l or stare air ern ission permits,the Action may
also emit one oar more greenhouse uses at or above the follo"ing leve Is:
i. More than 1000t�onslyear of carbon dioxide(CO,2) Mg 0
, More than 3.5 tonslyearo f n.trous oxide P,20) D2j 0 ❑
iii.More than 10100,rotrsr"year of carbon equrivolent ofperfluorocarbons(P s;) Deg
iv,More than,,0 45 tons/year of sulfur hexafl^uoride(Sp6) D2g
v. M,ore than 1000 tonslyear of carbon dioxide equivalent of D2g ❑, t�
hydrochloroaflmurccturbons(1 CF- s)emissions
A.43 tonslycar or more of methane D h 0 ❑
b,The proposed action may generate 10,tonslyea:r or snore oaf any orae desigmated D2g ❑ ❑
hazardous air pollurtan%or 25 tonslyeaur or more of any combination of such hamrdours
air eolletants.
c The proposed action.may requrire.a stere air registration,or may produce an ern ussions D2 f,,D2g ❑
rate of total conttutninants that may exceed 5 lbs_per hour,or may include a heat
source capable ofprodurcing,more than 10 mill inn BTUs Ecrhour.
d.The proposed action.may reach 501 of any two or more of the thresholds in"a" Dlg"D2k 10
throur "d"a,above.
e.The proposed action may result in the combustion or thermal treatment of more than t lis 0
ton of refuse per,hours„
f.Otliesr impacts: ❑
`. Irrrpact on Flants and Animals
T'lte proposed at;;t t n may result in a loss of flora or fauna. (See Fart 1. E.2.roti.-"q.) EI NO 13 YES
;5 win, an'sI've? U 'f�� Ifn '�'" move on ttr Section 8.
Relevant !aw or it++loul;eriate
Part I small, to large
'Question(s) impact impact may
rnaoccur o cou r
a.The proposed action may cause reduction in population or loess of individuals of'any Ego 0 ❑
threatenedor,ermdang,ered species,as listed by New York Mate or the Federal
overnment,that use the site,our are found on,over,or near the site.
b.The proposed action may result in a reduction or degradation of any,habitat used by 1320, ❑ �
any rare,threatened or endangered species„as,listed by New"'fork State or the federal
gcav�rmrrnBrut.
c.Time proposed action may cause reduction in Population,or loss of individuals,of any E Ia ❑'
.species of Special concern or conservation steed,as listed by New York State or the
Federal goverrtment,that use the site,,or are found on,over,or.near the site.
d..The proposed action may result in a reduction,or degT dstlon of any habitat used by Up to
any spe"oics of special concern and conservation need,as listed by New York,'grate or
the Federal ve.m meant.
'age 4 of 10
mpy occur occur
Upon review of Elie information recorded on this EAP".as noted, plus this additional support information
and considering both the magnitude and importance of each identified potential impact,it is the conclusion offfine
as[cad agency that:
0 A. This project will result in arca significant adverse impacts on, the environment,and,therefore,an environmental impact
statement need not be prepared. Accordingly„Eli is negative declaration is issued-
El B„ Ahhouagh this project could have to signirmant adverse impact on the environment, that impact will be avoided or
substantially mitigated because of the fol Ww ing,condidons which swill be required by the lead agency-
There will, therei'Or „be no significant.adverse ilrnpacrs,from die project as conditioned, and,therefbre,,this conditioned negative
declaration Is issued. A conditioned negative decUuMati:on may be used only for UNLISTED actions(see 6 NYCRR 617-d),
C. This Projem may resent in one or more significant adverse itutpacts on the eruvironmerut,and an environm ntal impact
statement must be prepared to further assess the impacts)and possible mitigation and,to explore alternatives to avoid or reduce those
impacts, Accordingly,this positive declaration iso issued.
Marne o f Acdon:
Name of Lcad Agency
Marne ofResponsible Officer in lead Agency:
Title of Responsible Offficen
Signature of Responsible Officer in mead'Agency', Date-
ignatuure ofPrepuarer(:ifdifferent from Responsible Offl'cer) mate:
For Further Information
Contact Person:
Address:
Telephone 1~'lturrnbu:r,
E-mail:
For Type ll Actlorus anti Conditioned Negntive Declarations,.a copy of this Notice is sent to:
Chief Execulive Officer of the political subdivision in which the action will be principally located(e-g-.,Towwwn7.I City I Village a'
Other involved agencies(if any)
Applicant(if any),
Environmental Notice Bulletin. ec ilk vleablen 12,11
P relini 6a ry Stap R*�vi sed A pri�20 10
Signature Page
'rh,is page kicludes: 1.) AuthorIzaticiii to Act us: Agpent Fo,rrn:� 2.,) Engineering Fee Disclosure; 3.) Authorization for Site
Visits; 4,) Other, Pemiiil't Responsibilitiea, 5.,) Officia] Meeting Disclosi.�,n? and 6..) Agreqm)aInt to provide documentation
required.
OWNER'S,Aa�ENT FORM'.
Complete the follbvdng ifthe,OWNER of the property is riot the same as the applicant
0-�,,ner:
Designates:
As agent regarding, Variance Site Plan Subdiyisiorl
For Tax Map No.: Section Sloc�k Lot
Deed Reference: Book Page Date
OWNER SIGNATURE: DAT E
APPLICANT's AG ENT FOR K.'
CompUte lhi�follovAing if the APPLICANT is vnabW to attend the meefing or wishies to be represented b,Y 1nother
party:
Owner:
Designates,: V�Wien a ala�l
As agent regarding: Var-i'llice Site Plan x Subdivision
For Tax Map I . swion Block Lot
" .3,33
Delect Refer e: k Pa-a e Date
OWNER SIGINTAT IURE: DATE:
?j, ENGINEERING FEE M5CLQ5 nay be referred to theTo-vin cansu[.1ing engineer for review 01septi: design,
Wag:� Applications r
storm drainage, et�, as delverniined by-he aning or Planning Fee�s far engini�e4rigi reviviv servio�s will lie charqrd
directlyto the ipplicanit Fees foranflirlttering reAew AH notexcead S I.-000 Mthom notlificafion to the applicant
FOR SITE VISITS: By zigtiing this page and SUbmitTing ihe application materials a��hzched �ierein, the
Cnv,ner, Applicant, an,d hisiherAI)eir agent(s), hereby mthorize the Zoning Board or, Planning Bolard and Town Staiff to enter ine
subjectproperiJes 1bT the wrpose of red evMV the
4.) OTHER PERMIT BESEQ_N�1131LITIES. Other pernilts rkl'aY UO ri�qjLdred for construtdan, or alteration actNity subse-quent to
It is the applicant's responsibilityto ol,)ltain an-yadditionail permits.
5-1 QFF1rIA"ZgjjU.Q INU7ES QlSaLQJU&g� It is the prcictice of the Cornaiiunity� Development Depaitment to, Mia�oa a
designated s tenogrmpher Lipe record t,,N proceedings of mer.-Lings resuking frorn, application, and minutes transcrIoad froni, those
tapes consdues lbe official re cofd of al I procee�lij V. s,
16.1 AGREEMENT IQ e8olgE.00CUMENTATION REQUIRED: 1. the, undersigned, have thoroughly read and, understand the
instruttions fcf subinifs sion a nd agreeto the subriiission requi remem. 1,acknowtedge no co ristruction actiMes shaIJ he ooninnenced
prior to Issuance of a valtd permk, I cenj�) ih3i: the applAcation, plans and suipparting mateilals afe, a true, and complete
statenienUd BsMption of Ule exisillng condiflons and thE� w'o* proposed, a nd that al] vvork wl I be performsd in accordance',NO�tW
approved plans and in conformin4*,,r;ith local zoning reguldtiorrs. I acRntmledge that pirforto loccuNng the facilities Proposed I!or
my,agents, wili obt,:,��n a ceirtificzate of occupancy as nace�sarj, I a[so understood Mat Vx;� nlay be reqwlred to provide an as-hullt
$UrVe,y IV a licensed land swve�j�w ofall nevAy constructed facilities prior to issuance ofa certificate of occupancy
I hav re, a ::e buv&
Mleg;han Cesari
Ig [Applicant] Print N�ame [Appiicant] Date S'lign,6d,
Matthew C. Steves
ignaftire[Agentj Prin't Name [Agent] Date signed
Town of Oueensbury.9anning Office!, 74�2 Say Roaid - Qui�ens�I)Qry, NY 128,04 618-71314220 T