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01 - Application & EA Form General Information Tax Parcel ID: 309.13-2-31 Zoning District: CLI Lot size: 6.9 acres Current Use: Building 1 - Health Center& Pharmacy Building 2 - Health Center Proposed Use: No changes to the current uses are proposed - project involves the installation of 240 lineal feet ohigh privacy fence along the west property line behind building #2. Project Location: 161 Carey Road, Queensbury, NY Applicant Name Hudson Headwaters Health Address: 9 Carey Road, Queensbury, NY 12804 Network Home Phone - Cell: 518-232-9663 Work Phone Tl d-924-2333Fax 518-745-1378 E-Mail: gpurdue@hhhn.org Agent's Name: Richard E. Jones Associates Address: 339 Aviation Road, Queensbury, NY 12804 Home Phone - Cell: 518-791-1960 Work Phone 518-793-1015 x 311 Fax 518-793-2223 E-mail ric ar hones rejaarc i ec s.com Owner's Name: Same as applicant Address Home Phone Cell Work Phone Fax E-mail Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804-518-761-8220 Additional Project Information 1. Will the proposal require a Septic Variance from the Town Board of Health? No 2. If the parcel has previous approvals, list application number(s): SP45-2010, SP46-2013, SP1 5-2014, SP52-2014 3. Does this project require coverage under the New York State Pollutant Discharge Elimination System (SPDES) Permit Program? No 4. Estimated project duration: Start Date 12/1/16 End Date 12/31/16 5. Estimated total cost of project: $12,000 6. Total area of land disturbance for project: 1,000 sf Floor Area Ratio Worksheet FLOOR AREA RATIO (FAR) --The relationship of building size to lot size, derived by dividing the total building floor area by the lot size in square feet, yielding a percentage. Zoning District Symbol FloorArea Ratio[FAR] Waterfront Residential WR 0.22 Commercial Moderate/Commercial Intensive CM / Cl 0.3 Main Street MS 0.3 A. The combined area of all square footage, as measure from exterior walls of all structures on the property, including all floors of the structures, garages, basements and attics with more than five (5) feet of ceiling height and covered porches. Building square footage does not include: Open deck, docks and that portion of covered docks extending over water and one storage shed of one hundred twenty (120) square feet or less. Any additional sheds will be included. (See"FLOOR AREA RATIO"). B. Commercial or industrial: the total area in square feet as measured from the exterior of the outside walls of a building or structure, and when applicable, the sum total of all floor areas of the principal and accessory buildings or structures on the project site. A. Parcel Area sq.ft. B. Existing Floor Area _sq.ft. (see definition above) C. Proposed Additional Floor Area sq.ft. D. Proposed Total Floor Area sq.ft. E. Total Allowable Floor Area (Area x ) (see above table) If D is larger than E, a variance or revisions to your plan may be needed. Please consult w/Staff. Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804-518-761-8220 Site Development Data Area /Type Existing sq. ft. Proposed Total sq. ft. Addition sq. ft. A. Building footprint #1 = 13,278 0 #1 = 13,278 #2 = 28,636 #2 =28,636 B. Detached Garage 0 0 0 C. Accessory Structure(s) 0 0 0 D. Paved, gravel or other hard surfaced area 149.993 0 149,993 E. Porches / Decks 0 0 0 F. Other 0 0 0 G. Total Non-Permeable [Add A-F] 191,907 0 191,907 H. Parcel Area [43,560 sq. ft. /acre] 300,564 0 300,564 I. Percentage of Impermeable Area of Site [I=G/H] 63.8% 0 63.8% Setback Requirements Area Required Existing Proposed Front[1] 50' #1 _ - Existing to remain Corinth Road #2 = 393'-11" Front[2] 50' #1 = 239'-3" Existing to remain Carey Road #2 = 151'-9" Shoreline - - Side Yard [1] 30' #1 _ - xisting to remain #2 = 44'-6" Side Yard [2] 30' #1 =61'-3" Existing to remain #2 = 80'-6" Rear Yard [1] - - - Rear Yard [2] - - - Travel Corridor 75' #1 = 83'-8" Existing to remain Corinth Road #2 = 393'-11" Height[max] 40 30' Existing to remain Permeability 30% 36.2% 36.2% No. of parking spaces 91 u Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804-518-761-8220 § 179-9-080 Requirements for Site Plan Approval. The Planning Board shall not approve a Site Plan unless it first determines that such site plan meets the following Standards. Please prepare responses to each of the following topics. STANDARDS A. -EL The proposed project furthers or is consistent with the policies of the Town's Comprehensive Plan. B. —. The proposed project complies with all other requirements of this Chapter,including the site plan review standards as set forth in Paragraph F of this section,the dimensional, bulk,and density regulations of the zoning district in which it is proposed to be located(Article 3 and Table 1), the applicable requirements of all other Articles that apply. C. The site plan encourages pedestrian activity internally and, if practicable, to and from the site with pedestrian paths or sidewalks connected to adjacent areas. D. The site plan must conform to Chapter 136 Sewage and Sewage Disposal, Chapter 147 Stormwater Management Local Law, and other applicable local laws. E. the proposed use shall be in harmony with the general purpose or intent ofthis Chapter,specifically taking into account the location,character and size of the proposed use and the description and purpose of the district in which such use is proposed,the nature and ntensity of the activities to be evolved in or conducted in connection with the proposed use and the nature and rate of any ncrease in the burden on supporting public services.andfacilities which will followthe approval ofthe proposed use. F. The establishment,maintenance and operation of the proposed use will not create public hazards from traffic,traffic congestion orthe parking of vehicles and/or equipment or be otherwise detrimental to the health, safety or general welfare of persons residing or working in the neighborhood or to the general welfare of the town.Traffic access and circulation, road intersections, road and driveway widths, and traffic controlswill be adequate. G. Off-street parking and loading facilities will be appropriately located and arranged and sufficient to meet traffic anticipated to be generated by the new use. The establishment ofvehicle links between parking areas of adjacent properties are provided where feasible. This furthers the Town's goal of reducing curb cuts and reducing congestion. A twenty-foot wide connection is required. If adjacent properties are either undeveloped or previously developed without having made provision for future linkage, then a future connection must be identified and provided for in the site plan under review for such future linkage when the time arises. The Planning Board may require proof that the applicant has made contact with adjacent property owners for purposes ofcoordinating linkageswith adjacent properties. H. The project shall not have an undue adverse impact upon the natural,scenic,aesthetic,ecological,wildlife,historic,recreational or open space resources of the town or the Adirondack Park or upon the adequate provision of supporting facilities and services made necessary by the project,taking into account the commercial,industrial,residential,recreational or other benefits that might be derived from the project In making the determination hereunder,the Planning Board shall consider those factors pertinent to the project contained in the development considerations set forth herein under§179-9-080 of this chapter,and in so doing,the Planning Board shall make a net overall evaluation of the project inrelation to the development objectives and general guidelines set forth in§179-9-080 ofthisArticle. I. The provision for and arrangement of pedestrian traffic access and circulation,walkway structures,control of intersections with vehicular traffic and overall pedestrian convenience shall be safe and adequate for pedestrian movement Pedestrian connections between adjacent sites shall be provided to encourage pede5trian use. J. Stormwater drainage facilities will prevent an increase of post development drainage flows as compared to pre-development drainage flows. Drainage of the site shall recharge ground water to the extent practical. Surface waters flowing off-site shall not degrade any streams or adversely affect drainage on adjacent properties or public roads. Facilities shall be inconformance with the drainage standards of Chapter 147of the Town Code and the Town of Queensbury Subdivision Regulations where applicable. K. The water supply and sewage disposal facilities will be adequate and will meet all applicable and current requirements set forth by Department of Health regulations and Chapter 136 of the Town Code. L The adequacy, type and arrangement of trees, shrubs and other suitable plantings, landscaping and screening shall effectively provide a visual and/or noise buffer between the applicants and adjoining lands, including the maximum retention of existing vegetation and maintenance, including replacement of dead or deceased plants. M. Fire lanes,emergency zones,and fire hydrants will be adequate and meet the needs and requirements of emergency service providers. N. The design of structures, roadways and landscaping in areas susceptible to ponding, flooding and/or erosion will minimize or avoid such impactstothe maximum extent practicable. 0. The site plan conformsto the design standards,la ndscapi ng standards and performance standards ofthischapter. Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804.518-761-8220 § 179-9-050 Application for Site Plan Review Absent any waiver or waivers, an application for Site Plan Review shall include the following: REQUIREMENTS Sheet# A A vicinity map drawn at the scale that shows the relationship of the proposal to existing community facilities which affect or serve it, SP-1 such as roads, shopping areas, schools, etc. The map shall also show all properties, identify owners, subdivisions, streets, and easements within 500 feet of the property. Such a sketch may be superimposed on a United States Geological Survey map of the area. B The site plan shall be drawn at a scale of forty feet to the inch (1"=40 feet) or such other scale as the Planning Board may deem SP-1 appropriate,on standard 24"x 36'sheets,with continuation on 8)12"x 11"sheets as necessary forwritten information. The information listed below shall be shown on the site plan and continuation sheets. SIB-i C Name of the project, boundaries,date, north arrow,and scale of the plan. D Name and address of the owner of record,developer,and seal of the engineer, architect,or landscape architect. F the applicant is not SP-1 the record owner, a letter of authorization shall be required from the owner E The location and use of all existing and proposed structures within the property, including all dimensions of height and floor area, all SP-1 exterior entrances, and all anticipated future additions and alterations. F The location of all present and proposed public and private ways, off-street parking areas, driveways, outdoor storage areas, SP-1 sidewalks,ramps,curbs,paths,landscaping,walls,and fences. Location,type,and screening details for all waste disposal containers shall also be shown. G The location, height, intensity, and bulb type.(sodium, incandescent, etc.) of all external lighting fixtures. The direction of illumination NA and methods to eliminate glare onto adjoining properties must also be shown in compliance with §179-6-020. H The location,height,size,materials,and design of all proposed signs. NA The location of all present and proposed utility systems including: NA 1. Sewage orsepticsystem; 2. Water supply system; 3. Telephone,cable,and electrical systems; and 4. Storm drainage system including existing and proposed drain lines,culverts,catch basins,headwalls, endwalls, hydrants, manholes,and drainage swales. J Plans to prevent the pollution of surface or groundwater, erosion of soil both during and after construction, excessive runoff, and NA flooding of other properties, as applicable. A Stormwater Pollution Prevention Plan (SWPPP) for all land development activities (excluding agricultural activities) on the site that results in land disturbance of 1-acre or more. A SWPPP shall comply with the requirements of the DEC SPDES MS-4 General Permit and Chapter 147 of the Town of Queensbury Code. It shall be at the discretion of the Planning Board as to whether a SWPPP or an erosion and control plan shall be required for a site plan review project land disturbance of lessthan 1-acre. K Existing and proposed topography at two-foot contour Intervals,or such other contour interval as the Planning Board shall allow. All NA elevations shall refer to the nearest United States Coastal and Geodetic Bench Mark. If any portion of the parcel is within the 100- year floodplain,the area w!II be shown,and base flood elevations given.Areas shall be indicated within the proposed site and within 50 feet of the proposed site where soil removal or filling 6 required,showing the approximate volume in cubicyards. L A landscape plan showing all existing natural land features that may influence the design of the proposed use such as rock outcrops, NA stands of trees, single trees eight or more inches In diameter, forest cover, and water sources, and all proposed changes to these features including sizes and types of plants. Water sources include ponds, lakes,wetlands and watercourses, aquifers,floodplains, and drainage retention areas. M Land Use District boundaries within 500 feet of the site's perimeter shall be drawn and identified on the site plan, as well as any SP-1 Overlay Districtsthat apply to the property. Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804.518-761-8220 REQUIREMENTS CONTINUED Sheet# N Traffic flow patterns within the site,entrances and exits,and loading and unloading areas,as well as curb cuts on the site and within SP-1 100 feet of the site. The Planning Board may,at its discretion, require a detailed traffic study for large developments or for those in heavy traffic areas,which shall include: 1. The projected number of motor vehicle trips to enter or leave the site, estimated for weekly and annual peak hour traffic levels; 2. The projected traffic flow pattern including vehicular movements at all major intersections likely to be affected by the proposed use of the site; 3. The impact of this traffic on levels of service on abutting public streets and at affected intersections. Existing and proposed weekly and annual peak hour traffic levels and road capacity levels shall also be given. 0 For newconstruction or alterationsto any structure,a table containing the following information shall be included: SP-1 1. Estimated area of structure to be used for particular purposes such as retail operation,office, storage, etc.; 2. Estimated maximum number of employees; 3. Maximum seating capacity,where applicable;and 4. Number of parking spaces existing and required for the intended use. P 1. Floor Plans. NA 2. Elevations at a scale of one-quarter inch equals one foot (1/4" = 1 foot)for all exterior facades of the proposed structure(s) and/or alterations to or expansions of existing facades, showing design features and indicating the type and color of materials to be used. Q Soil logs,water supply well and percolation test results,and storm runoff calculations, as needed to determine and mitigate project NA impacts. R Plans for disposal of construction.and demolition waste, either on-site or at an approved disposal facility. NA S Plans for snow removal,including location(s)of on-site snow storage. NA T An Environmental Assessment Form("EAF"),as required by the SEQRA regulations,with Part 1 completed by the Applicant shall be Attached submitted as part of the application. If the proposed project requires a special use permit and an EAF has been submitted in conjunction with a special use permit application,a duplicate EAF is not required for the site plan application.. U If an application is for a parcel or parcels on which more than one use is proposed, the applicant may submit a single application for SP-1 all such uses provided the proposed uses are accurately delineated on a site plan drawn pursuant to the requirements set forth above. The Planning Board may grant the application with respect to some proposed uses and not others. For purposes of reviewing an application (and for SEQRA compliance) all proposed uses on a single parcel or on contiguous parcels shall be considered together. V A brief narrative statement on how the project proposed for review furthers or is consistent with the vision,goals and policies inthe Attached Town's Comprehensive Plan. Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road Queensbury, NY 12804.518-761-8220 Pre-Sub�mission Conference Form [179-4-040] 1. Tax Map ID 309.13-2-31 2. Zoning Classification CLI 3, Table of Allowed Uses 0i f)Ql,�2 C_!"v:E_ -F c�_ subject to Site Plan Review 9 4. Ordinance Section /1'( 5. Pre-Submission Meeting Notes; Outstanding terns To Ofe BeA ssed Include; Deed �y, No General Information complete No Site Development Data Complete Y�I S_ No Setback Requirements Complete y No Additional Project Information Complete Yep) No *Coverage under DEC SWPPP Program yk"'A No FAR Worksheet complete Y, No Standards addressed No Checklist items addressed y No Environmental Form completed No Signature Page completed est No TM 2 L/C LA-12C e'j C 1011 (7)Cj_�2�1 C L, E 2/'\ /A, r Cre C., C­- i')"') C'A t 'I L C"I'S c", �X' r—Cj�o-f' ........ Lo eV *Applicant must provide office with Ngtigg of In NOi)° SWPPP Accegjangg Form, DEC letter issuing germil number: Notice of Termination (NOT) Staff Representative: C' Applicant /Agent,- Date: Site Plan Review Revised April 2016 Town of Queensbury Planning Office-742 Bay Road-Queensbury, NY 12804°518-761-8220 ........... Signature Page This page includes the 1)Authorization to Act as Agent Form: 2.) Engineering Fee Disclosure," 3.)Authorization for Site Visits;, 4.) Other Permit Responsibilities; 5.) Official Meeting Disclosure and 6.) Agreement to provide documentation required, OWNER'S AGENT FORK Complete the following If the OWNER of the property is not the same as the applicant Owner: Designates: As agent regarding: Variance Site Plan Subdivision For Tax Map No,: Section Block Lot Deed Reference: Book _Page Date OWNER SIGNATURE: DATE: APPLICANTS AGENT FORM: Complete the following if the APPLICANT is unable,to attend the meeting or wishes to be represented by another party Owner: Hudson Headwaters Health Network Designates.- Kicriard It. Jones Associates Arctiltects As agent regarding: Variance X Site Plan Subdivision For']ax Map No.: 309.13 Section 2 Block 31 Lot Deed Reference: 4092 B fl6Page 9/23/10 Date APPLICANT SIGNATURE. DATE: 10-17-2016 J 2.) ENGINEERING FEE DISCLOSURE: Applications may be referred to the Town consulting engineer for review of septic design, storm drainage, etc. as determined by the Zoning or Manning Department. Fees for engineering review services will be charged directly to the applicant. Fees for engineering review will not exceed$ 1,000 without notification to the applicant. 3.) AUTHORIZATION FOR SITE VISITS: By signing this page and submitting the application materials attached herein, the Owner, Applicant, and hisiher/their agent(s) hereby authorize the Zoning Board or Planning Board and Town Staff to enter the subject properties for the purpose of reviewing the,application submitted. 4,) OTHER PERMIT RESPONSIBILITIES: Other permits may be required for construction or alteration activity subsequent to approvai by the Zoning Board or Planning Board. It isthe applicant's responsibility to obtain any additional permits. 5.) OFFICIAL MEETING MINUTES DISCLOSURE: It isthe practice of the Community Development Department to have a designated stenographer tape record the proceedings of meetings resulting from application, and minutes transcribed from those tapes constitutes the official record of all proceedings, 6.) AGREEMENT TO PROVIDE DOCUMENTATION REQUIRED: 1,the undersigned, have thoroughly read and understand the instructions for submission and agree to the, submission requirements, I acknowledge no construction activities shall be commenced prior to issuance of a valid permit,, r certfy that the application, plans and supporting materials are a true and complete statement/description of the existing conditions and the work proposed, and that all work will be performed in accordance with the approved plans and in conformance with local zoning regulations. I acknowledge that prior to occupying the facilities proposed, I or my agents, will obtain a certificate of occupancy as necessary. I also understand that Ilwe may be required to provide an as-built survey by a licensed land surveyor of all:newly constructed facilities prior to issuance of a certificate of occupancy I have reMadage o the above. George Purdue, CAO 10-17-2016 signature[App'cant] Print Name [Applicant] Date signed Richard E. Jones, Architect 10-17-2016 gignature [Ag t] Print Name [Agent] Date signed Site Plan Review Revised April 2.016 Town of Queensbury Planning Office. 742 Bay Road Queensbury, NY 12804 518-761-8220 ..............------ 617.20 Appendix B Short EnvironmentalA ssessment Form Instructions for Completing Part 1-Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification . Complete Part I based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1-Project and Sponsor Information Name of Action orProject West Mountain Health Services - privacy fence Project Location (describe, and attach a location map): 161 Carey Road, Queensbury, NY (Warren County) Brief Description of Proposed Action: Construct a new privacy fence along a portion of the west property line behind Building #2. Name of Applicant or Sponsor: Telephone: 518-824-2333 Hudson Headwaters Health Network E-Mail: gpurdue@hhhn.org Address: 9 Carey Road Quee sbury State: NY Zip Code: 12804 1.Does the proposed action only involve the legislative adoption of a plan, local law,ordinance, NO YES administrative rule, or regulation? If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that X may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2.Does the proposed action require apermit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: Town of Queensbury Planning Board -site plan review X 3.a.Total acreage of the site of the proposed action? 6.9 acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties) owned or controlled by the applicant or project sponsor? 14.78 acres 4.Check all land uses that occur on,adjoining and near the proposed action. o Urban YRuml(non-agriculture) X Industrial X Commercial o Residential(suburban) oForest oAgriculture oAquatic o Other(specify): o Parkland Page 1 of 4 5. Is the proposed action, NO YES NIA a.A permitted use under the zoning regulations? X b.Consistent with the adopted comprehensive plan? X 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? X 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: X 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES X b.Are public transportation service(s)available at or near the site of the proposed action? X c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? X 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: X 10. Will the proposed action connect to an existing public/private water supply? NO YES If Yes,does the existing system have capacity to provide service? ONO O YES If No,describe method for providing potable water: Existing municipal system X 11.Will the proposed action connect to existing wastewater utilities? NO YES If Yes,does the existing system have capacity to provide service? O NO O YES IfNo,describemethodforprovidingwastewater treatment: Existing oil-site septic system X I2. a.Does the site contain a structure that is listed on either the State orNational Register of Historic NO YES Places? b.Is the proposed action located in an archeological sensitive area? X 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? X b.Would the proposed action physically alter,or encroach into,any existing wetland orwaterbody? X If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: 0 Shoreline X Forest 0 Agricultural/grasslands 0 Early mid-successional 0 Wetland 0 Urban X Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? X 16.Is the project site located in the 100 year flood plain? NO YES X 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, a.Will storm water discharges flow to adjacent properties? ONO O YES X b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? IfYes,briefly describe: ONO O YES Page 2 of 4 18.Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: X 19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: X 20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or NO YES completed)for hazardous waste? If Yes,describe: X I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorname: Richard E. Jones, Architect Date: 10-17-2016 Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context ofthe proposed action?" No,or Moderate small to large impact impact may may occur occur . Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing community? 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit, biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a.public 1 private water supplies? b.public 1 private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources (e.g.,wetlands, waterbodies, groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur I0. Will the proposed action result in an increase in the potential for erosion,flooding or drainage problems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why aparticular 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 detail,identify the impact,including any measures or design elements that have been included by the project sponsor to avoid orreduce impacts. Part 3 should also explain how the lead agency determined that the impact mayor will not be significant.Each potential impact should be assessed considering its setting,probability of occurring, duration,irreversibility,geographic scope and magnitude.Also consider the potential for short-term,long-term and cumulative impacts. o Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. o Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from Responsible Officer) Page 4 of 4