Environmental Assessment Form Short Environmental Assessment Form
Part I - Project Information
Instructions for Completing
Part I -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 I - Project and Sponsor Information
Name of Action or Project:
Project Location(describe,and attach a location map):
Brief Description of Proposed Action: 7'
1,7
Name of Applicant or Sponsor: Telephone: V
-5;/ E-Mail:
Address:
City/PO: State: Zip Code:
1.Does the proposed action a 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 O'D
may be affected in the municipality and proceed to Part 2, If no,continue to question 2.
2. Does the proposed action require a permit,approval or funding from any other governmental Agency? N4 YES
If Yes, list agency(s)name and permit or approval: D" El
3.a.Total acreage of the site of the proposed action? _���" acrcs ��
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? acres
4. Check
uses th occur on,adjoining and near the proposed action. - z
ural (non-agriculture) 01ndustrial E]Commercial Residential(suburban)
I Iano Forest at
st F
_lAgriCUItUre 0 Aquatic E]Other(specify):
F
ElParkland
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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:
Ef ❑
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: ❑
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO
I completed)for hazardous waste?
If Yes,describe: F]
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name* A Date:
Signature;
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