Site plan application Ger ral Infor aflOn
Zoning District,
Lot size,
Current Use 2 1,
, ...
Proposed Use:
"rt, , n "
Applicant Name dr o.as
el
Gelb
Home, Phan � �
Work Phone
_ ( F@x
E,Mall,
Home Phone: ti:
'Workdun
Owner" frarg"
Home Phone
Work P`ioru �� FPS'
E-mail 6A
/ *
aft Plan Review RtMead June 2DIG
Tpwn Pf QueenebmPlann N Office,742Day d. � a ' 12844-:51110.761. 0
I
1, Wilithe proposal require a Septic Vari nce from the Town Board of Health:'?.Lgp ,
Ifthearcelhas, t application r�o� �S}.ha
. Kathie project require coverage uder the New York State Pollutant Discharge Elimination System
, Estimated project duration: 'Start Date—, Enid Date..
Estimated total coat of project:
6. Yogi area of land disturbance for pro]act: 74,aL...—
F190—r Area Ratio,Woftheet
FLOOD AREA RATIN(FAR)_o The relation ship ofbuilding Giza to lot size.,derived by dividing the total building
floor area byy the lot;size in square feet,yieldl ng a percentage.
e,.
Zoniq UsWd Symbot Flooir Area Ratio[FAR]
olr7ru:meroioli Iw odaratue/ otl m rcial,intensi Ill/ l 0.'
V MS l "
., The oomblr d area of all square footage, a measure from exterior walls of all Structures on the propert , Including
A111 floors of the structures, garages, basements and attics with rnoTe, than five (6) feet of r lling height and
coveTed porches. Building square,footage does not include: Open dam,,, docks and that portion of covered docks
extending over water and one storage s ed of one hundred twenty (120) square feet or less, Any additional
sheds will be inn a ed.(See"FLOOR AVS ' F TI °" ..
Commercial or Industrial, the total( area ir i square feet as measured from the exterior of the outside walls of a
building or structure, and when applicable„ the suaulrvn totl of all floor areas of the grin ip l-and accessory buy ild rugs or
structures on the project site,.
A. Parcel Area
B, Fxlsting Floor Area, set.ft. see dei inition above)(
C. Proposed Additional H sq.
Dv Proposed"T'otaI Floor Area sq.
E. Total AV'lowwrableFloor Area _ (Area x (see abut table)
If 0 is larger than E, a variance or rev,sibns to your,Ebrn may be needed. Please consult wlstaff.
'al:to FISn WgWd June 2015
T nstruury guru ngOffVu -742 Day Road !Q gyrus ury"NY M04-6181-761-Mo
3
fit evelp meet DMA
Area I Type Existing eq, ft: Pry W Total, w ft,
Ad
dltlg�, -ft.
ap= 800C)
Coo
C":
Q pt„gruel or other hard surfaaad are
E. Porches)Dock's
Fri Other
H. Pamelrey J43,560 sq.I I actel �� � ;2
I. Percentage of impermeable Area of Gfe- [u= HI
LGLEmiremaLs
Area ExistingProposed
Front Ill
50
Front Iii
nl�
Side Yard ['til
Olde Yard 121 ,
ler'YrdIIS
Deer Yafd 121
---Travel-Corrldoir
Height(max]
Permeability :3070
No of pa,?gl spaces 01
179-9-080 �ai� ��t7 � ����� �,, woval Th PlanningBoard shall not approve Site Plan Unt ss it.
first determines that such site ply Tnee th llowin l��td�rds. 'i prepare r g��l� s to each ��
following topics:
S
TANDARDS
S
A. The used project furthers ter,is n,ststeat v d1b policies of the To wn ; a 'hey sive Plan.
' project complies with all wutluer require arts of this Chapter,including the sits pleat review standards as set forth in Pat' ph
is sectio Ip the dirnerrsional,bulk and density ailtdions of the zoning district in v 4iieh it is prurposed to be located��rticle 3 auuad
TabC, encouragesPp rmuwrnean acotivill other ernaV lea nd�if practicable to auvrl
the les that OY.
Pesatrian frr the site with pedestrian paths sidewalks ctururneua
cent areaas
le pl musk nforatt'tc+aha r 1,36 ewua e d Disposal,Chapter t47 trvu cavwarcr VA�taawaigcwe went Local lAww',and other
hwa
appl
The
sed use Il be is harmony with the gene l uu far untent of this
character and size of the Proposed,use and the descr prion and,purpose ofthe district irurww hick such use is proposed,, he natuuto 04,int:enslty
ii'u�the iZtiWZ
' t
of the activities to be involved'inter conducted in ectkm with,the proposed use and die nature and rale of any increase in the burden on
supporting public s °icees and fheiliti which,
will,bl ower the approval of the proposed use.
p l %N,"es
cstsbiislwrncn4 maintenance and opc ,tion of'tlu a �d use win not public hazards from trs *traffic congestion or t
he
paiking of vehicles and/oT equipmentor be otherwih a detrimental to the health,safety or general welfare of Perms tiding or wDrkin,g in,
the neigbborhood or to the general ww el,farre ofdm tut'uu= TrafVi;e access and circualatla m,road iratersectiorusw,road a n d way vwidths end.
traft ee'nntr is
ublyowWl be adequate.dc t
vnir1 d arranged,� nt utraffic fbceaa
fstreet parking 19aprovided wh-r-
c links s � P
.generated by de new use. The establishment of we uxcion is required,., lfadCacert
This furtles the T n',gold ofredic nge<rbcaand reducing rscion. A t%wnty-fbot wide conne
prarpe i sue ea r on to or wiauisly loped Ath �uk having made provision filar future lice„then a.fnutuure connection must `
be idcntiCiewl and pt aided for in llte site plan Lund reviewforsach futureIinVra�e wvdneuu the tiurre arises. 'fie Planning,t�ouurd may require
prrnarf that the applicant has made ntaa t ltln as ja nl Property owners for purposes a f mordinaLting linka ggs with adjacent properties,
R. project shall not have undue ver impactupon the natural,scCn ;aesdid ecological, liliesfe,historic„ s Ma", al Or OPen
space resources of the,town or the Adirondack P or upon the adequate provision of sopportuar�facilities and services uruacle necessary by
tut be derived from tine �e
the pra�,�'� y talC."tTi' into account t coounaerclanl',in aastrusl,residential,recreational orother beni�that ruailg y
In.maldAg the determination hinder,the Plana° Board sliall ntider those factors peutinent tD the project contained in the
Chapter,and in sir doing,the Planning Board I matte a trey call
development considerations set l"otlu herein,wider 1'a - flgft tuf thins tat , g
evaluation of ft Project in relation to lige developn enk objectives and gencaail guuidezlines set ferth in§M-91-080 ofthis Articic.
"flue prowtision for.and arrangement of ian tr ffia arcs s and circulation,walk-way struactuuees;contrtal��intersections with wehicnlar
traffic and overall pedestrian convenionce sh-axll be &sand adequate for pedestrian moveme tt. Pedestfian uarueotimns beton adjacent
sites shall be provided to encourage pedestrian use
» " per. p .'t&Srral $V�as Compared n cufl�deve ilea
p vw�tefs fluor g not degrade any
t3torruwte�dn�warn Sa�ut'ltt� 111 revervt ua ear»;, ase of at development mn are+d cru l nu�rul:draanaugpa
flows, fJNraa ,ge ofthe site shall aech �anud ter Clue.erutcnt uarface
s s or adversely affect drainnago on adjacent p erties or public roads. Facilities shall,be in conformance with t am standards
of Chapter 147 of the Town Code,and the Tovm ol QueerisburySubdivision Regulations where applicable. '
flue
wva r suuppulsuupguly and sawago disposal facilities wi it'be adequate and will meet all appliza le and current requirements.set forth by
Dcpartirruent of Health regulations and hapaer 13 of theTown Chide,
* The ade uuacy,type and aurrangel� nt of trams,sh s and ether suuifwulule piauntings,landscaping,and.screening shall.effectiVely provide a
visual anWo°noise bufferbetwean the applicants i nd adjoining lands,including the maximum retention of'existing vegetation and
Fire lanes,emergency zones and fixe hydrants
i nand phtnts_ uimtnnents of emergency service _ vridrrs.
maintenance,inchrdiugg replacement of dead
M.
is ww^ll be adequate and.rneettlic needs and rg^e cy?" quer .
N. "Clue design of s nctuires,.roadways acid landscape in aureas;sos table to ponding flooding and/or crrrsion will mi�,lrrui �r avoid r
impacts to the maximum extent practicabK.
—671 r
'lire site plata conforms to the,design standards,l ,Ascaping S and perfrurmoance standaards,of this chapter. '
le Plan view Revised funk*2016
Town of Quomsbury Mining fl ca-742 Bay Road,Queensbury,NY 12804-518-7614220
5
Absent any waiver or waivers,an apiication ,>we itPial Review&hall include the fol l wing:.
„
. 'T° _ lrt
Li
r<p wpiioity roust drawrurt aurthe,scale float shunT= continjuatioiton
the Telp Ofthe proposal existing community facilitics which affect
a r i as.roads,shopping map shall also how all properties,id�ify owMners,
su bdivisiicrw�sy s is and easements withinrops'. Suds a sketch may be snuperi ed oust,a United Mates
t an Ica t of the ares-
The
rea (
the i ch
rfeeruuu�pp te plan � standard sbe drawn at 9.Sale of forty feel tunatnnn uun Sit" I IS"" eels nc The Planning itten may
itt;foa.iation. The ienfonnation lisped below Shall be howaa'na on the site Plan and continuation stets:.
Nam of the project,bouaurdaries,lots,north arrow, md scale of plan.
ID 'l^wl'anue stud adds of the anwwncr ofrecord,devetope„and of the eu lrueer"arebiteat or l ape architects If tllnve �
a li not the mord oymer a letter of thor" tion lI be to unfired from the c et.
e location and use of all existing and pruo<posed st ictuurea within the p wperty,in,41ndin�all diuuuensianns afbeight and
floor area,all exterior cntra--- and all aA&i,2l tcd fur�uure additiauuus sand alteu atuons.The location,of all present and proposed public and prim ww�u'ys,al£st et p aureus,�d�vew y's„cordons s�arage aTe ,
sidewalks,ramps,ramps,,curbs,paths,landscaping,wwwalls d t,ences, I,,ocation,,type and screening details fu T all waste disposal � p
contai ,rs shell also lie shrr-vruu.
The location,Wght intensity bulb type(Both ,in auudescent„eGe,� ofall external lighting fixtures. di ekioo of ,..
illutrii uatiurn and methods,to a liurniruate ame orutn a ininu rrd ernes uuutiusr i be stnawwruu fiat liauncc with I79-6-0D 'O.
The lorafkvauu,height,size,,materials and design ofa:I proposed Sigm.
-7
Tile.'location mall piestotan.d proposed utdlfty syst=s including:
I. 'Sew ago or septic system;
1 Water supply system;,
3. Telephone,ne,cable and electrical systems and
4,. Stun, drainage systema including moist rug an propuscildrain lines,ouulverts,catch basins,headwalls,endwwral:ls,
hydtawru't$:,manholes arnd drainage sww"ailes.
plans to prcwcnt Ole pualluudon of Sftr6u 2 of gmulldl vatercrosion of sail hcth duuritng and,aftTa s'uxua tiaun,u a ssiwre rurnoll
and flooding of other properties,as applicable teirnuwPater Pollution Prevention flan(SAF)fbr all land du;vebYporent
ectiw"'itles(excluding,agricultural activities)on the i ite that:results inlend disturbanim orom acre or Toore. A SWFFP shall,
comply with illus mqunirennents of'the DEC SpDES I AS4 General Permit and Chapter 147 of the Toru ofQueensbury
Code. it shall be 4 the discrebonu sof the:Planning oaird as to wwdnether a SVVPPP or an erosion and control plan sbatt be
i
required for a site plan review pu-ojeet iariai distuTht uace ori-'lei
than one Vie.
Existing and,,pwposed toporophy at furan-foot urr intcn7als"or such,other contour interval as the'l°'l,arming Board shall
;allow, All elevations shat refer to,the noaftit Uni i d Stiocs Coastal and Goodetac Bene Ma& if any pordonofthe par=t
is vwatiuiuw the I loll- cr flcuodlrlaian,the aswarill be
puunpuwsc own and esu lI ele"wadi; s given. tlnall be utadiroedvthit
the proposed site and wvithmn 50 feel ofthe site where,sail removal or filling is required,;tkuauwving the approximate
vary in cubic y
LM A landscape plana showing loll existi nanatufal land fcatu duan may influence the design of theproposed use such as rock
ountero ,s,stands of s,single trees eight oar unum inches in diameter,forest and water sources and all proposed
changes to tbwe features,including sig and type ofplants. 'WW"atter sources include ponds,later elands and,
watercourses,aquuikm,Cloodplains and drainage. entloan a mss.
hand Use District boundaries within 5010 flet ofth sites peritruetewr shall be drao andideuntifi oonthe site plait,aswell
El4lnlay] ill that apply the pprs
Site Plan Revieww Ravised June 2016
Town OfQueensbury planIning rose""741Bay Road,Queembury,NY 12804•519-761-9220
6
REQUUtE4 MIENTS (CONTINUED)
Traffi-O flow patterns within tbr site,enTrancesand Vits,loading,and Wiloading areas,as well as Curb cuts onthe site and
within 100 feet of the site, The,1"l aim Board may'� at its dtwreit on.require a,detalled traffic study for large,dEvelopmnta or
for those in heavy traffic arem�,which shall include.
1. The projeeted number of motor vehicle trips 13 enter or leave The site,estimated Car weekly and
annual peak hour Wric lavr1s;
2. The pmjected traffic flow pattern including%ehicular movements at sil,moL*intersections likely
to be aflacted by the Proposed ease ofthcsite,
1 The irrupt orthis trafflo on levels of service,an,abutting public streels and at affected
inter=tions, Existing and proposed WacklY and annual peak hour traiTic levels and road capaertY
levelsshall also be given, table:containing the following in floonatiGn shall be included-.
0. For new construction or allemfionsto any structm,
1. Estimated area oratructure to be used for pa icular purposes sucb as retain OPcyal'Onl Off1w,
StUrAge,etcq
2. Estimated maximum number of employees;
3. Maximum"sting capacity,where;applicabl..;and
4. Number otparking spaces existing and requirexi(or the ira-nded,use.
P. 1. rkKFr H=. rue fGt(lj4.I-I fbotljor all exterior,facades oftheploposed struCture(s)
2. Flevations at a scale ol'one-quarter inch e:quals ;an
and/or alterations to or expansions of exiging fac , e%,showing desip lealntrc�i and indicating the typed color of materials
to be used. no��ff calculations as needed,to eine and
s, ter su ply well and pcToolatton test ref ults;,and sbmn
Q- S�lt logs, , p water
mitigate PT.Pjcct impacts,
—plans for disposal of construction and demolition #1e,either on-site or at an Opp disposal facility,
Mans for snow rerimal,including location(s)of -sk snow storage.
mrit
T. An E ental Ams=ent Form("SAF);&S Too with Dart 1, mpleted�y the Applk
ire a special use permit and an,EAF has been
shall be submitted as part of applical�lon. Ifthe propomd P roicot .requs
submitted in conjunction with a spoclal use PC ninil Wplication,a duplicate EAF is not required for the,site plan.application.
U. If an application is for a parcel or parcels on wt&h more than one use is prop�osK the applicant may s�ubmit a single
application for all such uses,provided the proposo�:�uses ore aceurately delincattd on a site, an day
punittant to the
requixtruerits set fbirth above. 'The FlannimS Board way Smm:the application with respect tO some proposed uses and not
othom Far pm:Tom Otreviewing",application(Kftd f0t$BQRA mmpliance)all ProWscd Uses on a single Parcel of on
cKmtiguous parcels"I be considered tWthcr.
V. Abrief narrative Mement on how,the project VTol*sad fo;review furthers or is consistent v*h the visiO%,goal3and policies
in the ow Comprebensivc Plan.
Site Plan Review Revised.June 2,016
Town of Queensbury Planning,0 Tiee-742 Bay Road,Queensbury,NY 12804.519-761-8220
7
'rem mission Conferente Form [ 9-4-0401
1, Tax Mop I O e L4 U- Q,- .,
,. Zoning Cleffefficaton
Tablb of Allowed Usee cc., suhjuot to Site,Plan Review
. Pre-Submiulon Muting 1 wtItems Ina ,
Deed No
General Information cornplete N
,Site Devdopment Data Complbte No
Setback ReqVirements,Complete No
ddiflo ral Project llrri ffnatlan,CompI to No
*QoverDEC 'PIP Pro r No
R Worksheet mrnplete, No
tandards,addressed Y No
Checklist leets addressEd No
Environmental Formcompleted Na
Signature Fuge completed No
,
r
c. fir, r r,
C
" %
APRIlgaint musti
aijM
:Notice r;afferminattaru
(NOT) toff Representative,,
pkt /Agent.;
Data:
VIA Ian F Vl w R@A atl Our 'l
Tmn of Quoenftry Planin no Mea 7149 Say'Rogod Quaan4lbury,My 12804-61 8-7,QJ.$ p,
Signature Page
This o e Inpludes the 1),Authorlization to AM as Agent Formi,2j lIngineeflng Foo 'Oeu'rey ,)Au ori zation for Site
"f f' p .), Other Perli osporII,Min; 1) C Molal Meeting Disol000re and .) ment to provide d cuma Iolo
10MER'S AGENT FORM:
onnplete,the following K the OWNER of the, p 'pbrty is not the saunas as the applicant � ,w
o rn 'm
Designates:
As agent regarding, SiW Mon, Subftlei
For Tax Map No.: WWI Block Lint
Deed Reference-nce- Nook Nage Dai
OWNER SIGNA7URE. DATE:
APPLICANTS AGENT
Complete the following I the APPLICANT ANaNNT i atA to attend sena rnu thug or hes to,be represented by another party
Owner:
Desi
As age tnregarding: Vadar Ce Site Plan
ubudiAsNorn
'For Tax Miap No-', seimhyl' Slock Lot
Deed Reference-. Book pep Date
;) ENGINE EE EMSCLOSURE. App4caticnis,may be, reed ID the Town -consulting engineer fai- review of septic design,
stoma drainage, etc: as delermInsid by the Zonligi or PI Irk i�epartn Fees for engineeringre%iew s will charged)
directly to the applicant. Faes Nor engineering will ru tzateed$ ju itn without,rnoti kation tri the applicant..
;j a�UTHORI wTI N FOR SITE,VISITS. Icy � �g is page and snnbrmitting the application materials shed herein,the Owner.
Applicant. :and hl0he r age nt(s) hereby au a line ming Board or planning ward and Town to 0, enter the subject
properties for the purpose:nI leuuuingi Ilya applica au'b nri .
4) 1 , R � � p" N'+I I .0, Or " r" may b@ r �y d for n Nr �q a r al ratim I in t,t I
ylbt ZoningKor w P%nning 699rd, Itlel
FMCm M TING MINUuTRK's DIS CISUR 1: It Is Ift,prni ofthili Gonmun wWoprn@n1:0cpattme tto have adntlgrni
Wrlogralpheir tap@ reporo th Proceed gaot in���rt uu�n�i��ppll i�na�n l nu n�arNb�d�r -�hosa Na� s n�s�l�� �
INnwcr aIN rated 'SIN pr� dInge,,.
) AGREEMENT TO PROVID DOICUMEN ; ION REQUIRED, t,t undemI n ro have ibuo �u b read and a ndvrMandl iia
In xucbons for submission and gree tD the su r slon mquulreunn , Il a inti a no construnctlan a vNes shall be commenced
yd
prior to issuance of a vali permits It at the application, plans, and stip rag rmatsAWs arra a truce and cornplate
statement0description of the bing carlditions 2 end the work proposed, and that all wo* Wil be performed In acc(*Ience vAlh the
approved plans and Inc ance with localzor ing reguulallons. I acknowledge that prier W ocrupyling the facilities proposed, i or my
agents,wiiil obtain a cert ofupan'wcy ars ni scessary, I also understand%at iu^iure may be required to,provide an as-bunt sunrey by
a INcansed land)surveyor all newly co pstrucled fi icillfles pdor tui issuance of a certificate GI occuipan'cy
I have, read and a to the above.
Signature
� iarr Tdilit Dame,[Applicant] Date signed
Signature[Agenq III t Name '[n ern'ft) Date signed,
$111ii Plain av 'Ro~Jur*2016
Town,of Q,ueensburyr Plannii ig Office-742 Bay Road) -Queensbury, NY 112804 ,518-761-8220
9
Short En *
Assessment Form
Pari' - Protect Information
Part l-projed Information. The appificant,or ro*t sponsor is respomible for the cats pAttiost of Part L Rcsponm
become part of the,application for appitoval or f"od oga are subject to public review,and may be subject to further verification.
,Complete Part l 'bar d on information currently available.. If additional research or investigation woeld be needed to frrlly
mpond to any item,please answer as thoroughly as i,possible based on.current infcrrrraation—
omplete all items in)Peart 1. You,rruaiy also provid6 anyy additional information which your believe:will be needed by or useful
to the lead „eru ra attach addit oral pages as nece, aryr to supplement any iters.
Fart 1 w project and Sponsor tur,forma,tiGn
Name of Action orPrgject
Pro°
sectccatuon(describe,ardd attach trca'tton
23 -
5uriefDescr•iption ofprcapused Action:
Name of Applicant orSponsor,- Tel ne.
E,-tail.
,address:
City/Po' Mate: Zip Code-
9.Toes the proposed action only:invol ,ttrc tog,alative adoption f a pia n tea 9 l�vr,ordina � O
administrative rule,or regulation?,
iffes,attach a narrative:description of the anted cf the proposed action and the er wortmental resDurues that
ma,,y be as "ected in the municipality and preaceedto'Part 2. If no,continue to question 2..
. 'Moes,theproPQsed action require a permits approval or funding from any cther'gweriarnental Agew. YES
if Yes,list a ency(s),name,arad p unit or approval,: r' -
3.aa.Total acreage of the site offhe proposed acti ore? aero
b.Total acreage to,be physically disturbed?, awes
c. ororatrrulped by flee appti caruor ct sponso
uo� s pra�pertiesp creed
y l
C Check all uses
F]Urban ElIaraC(u on-agriculture) Industrial
propped action.
occur on, J
gr orrrmerci;al EIResidential(suburban)
F rust OAgriculturre O quatic ElOther(spec*')-
ElParkland
Pap 1 tali
5. Is the proposed action, NQ— YES NIA
a.A,permitted use under the zoning regulation EJ
b.Cbosistent with the adopted comprehensive; lam
6, Is the proposed action consistent with the p rrrinant character of the existing,built or natural No Y
ES
landscape?
7. Is the site of the proposed action located in,or does it adjoin,a state listed Cntical Environmental area? No YES
If Yes, idea iifym
. aa,Will the proposed action resent in a substantial increase in traffic above prey t levels? NO YE
b..Are public transportation seTvic,e(s)availat:le at or mar the site of the proposed aetion?
c.Are any pededrian accommodations or bic ycle routes available on or sear site of the proposed action?
9� Dees the proposed action meet or exceed the s We energy code"arequirements7 No YE
If the proposed action will exceed requirements, rite design features and technologies:
Itp. Will the proposed)action connect to are existing publi ''private water supply? NO YES,
If No,describe method f'b!r providing pe table water:
II."bli"'ilI the prop ped action connect to,existing wastewater utilities? NO YES
If No,,,describe method for providing wastewater treatment.
12. a.Does the site contain a structure,that is listed on either the State or National Regi ter of Historic NO YES
Places? El
b.Is the proposed action located in an arebeological sensitive ? � I
13.a.Does any portion of the site of the pmpose d action,or lands adjoining the proposer)action,contain NO, YES
wetlands or other waterbodies cegidated by a federal,state or local agency?
b.,Would t the
proposed action physically alta„or encroach into,any isatin wetland or waterbody"?
If f
e wetland or waterbody andex ettt of alterations in square feat or acres-
14.
cres:I . Identify the typical' habitat types that occurr M,Or are likely to be d on the project.site,. Check all that apply.
Shoreline ElF"orest AMculturallgrasslands, Early mid-successional
EI h`rby
tland Urban .uuburbaa
e site of the proposed action contain y species ofan!mal,or associated habitats,,1'u"steel— �l" s
tate or Federal government as,unrest reed or,endangered?
roject site located In the 100;yam flo dl plain? YES.
1 I.mill the proposed action create strarm water dischMe,either from point or non-peint sources"? -NO YES
If Yes,
a.Will storm water discharges flogs to adjace it properties NO DYES Li
b.Will sterni water discharges be directed to established couvgyance systems(runoff and storrru drains)
If Yes,briefly des ribe.e LINo DyEs
oaf
19.,Does the proposed action includeconWaction,or other activities tbM result in the impoundment f YES
water oT other liquids(e. .retention pond,was to lagoon,dam)?
if Yes,explain purpose and size: r--1
Lj
19.Has the site of the proposed wion or an 401 lung propel"been the location of an active,ar closed NO_ YES
solid waste inanagement facilit "
IfYes,desuft
1Ias the si f'the puop �actino or an uudjcrl inn property lues,the sulub ettt of reuruedlora(ongoing,or 9q '
,0 '
completed)for hamdous waste?
If Yes,describe:-
Li
I AFFIRM THAT THE INFORMATION PR `'±'IDE dsBOV E IS TRUE AND ACCUFLATE To THE BEST OF MY
KNOWLEDGE
Applicaot"s ur r uu oe: uutte: �
i,gruetum.,
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" i 7' F Page 3 aft,
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A K U!S!0MuJjX Rf applicable)
Short Environmental Assessment Form
Part 3 Determination offtnifirance
For every qyestion,in Part 2 that was answerer odente to large impactmay occur",or if there is a need to,explain wily a
particular element of the proposed action may or will not result in a significant adverse environmental impact'please
complete Part 3.Part 3 should,in sufficient dffW, ,Werifify the impact,including any measures or design elements that
have been included by the pToiera sponser,tD avoi J or reduce impacts. Part 3 should also explain how the lead agemy
determimd that the impact may or will nGt be si I ificarit.Each poleotiall impact should be assessed considering its settiM,
probabil ity of occurring,duration,irm-vorsibility, p.-ographic;scope,and magnitude. Also consider the potential far short-
term,long-term and cumulative impacts.
Check this box if you have deternuned,baseon the in formatim and analysis above,and any supporting douna�tatic7n,
Haat the proposed action may result in on or more potentially large or significant adverse impacts and an
environmental hnpact statement is required.
Check this box if you have deterroiaed,bas on the informfion and analysis above,and any supporting documentation,,
that the proposed action evil not result in a significant adverse environmental impacts.
Name of Lead Agency Date
Print or Type,Nan of Responsible Officer in d AWney Title ofr Responsible Officer
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Sire of Responsible Officer in Uad, kgency Signature of Prepamr(if different&oTn Responsible Officer),f gnatu
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