Full EAF
[[880,75,1682,132][12][B,I,][Times New Roman]]Full Environmental Assessment Form
[[993,133,1607,190][12][B,I,][Times New Roman]]Part 1 - Project and Setting
Instructions for Completing Part 1
Part 1 is to be completed by the applicant orproject sponsor.
Responses become part of the applicationfor approval or funding,
are subject topublicreview, and may be subject to further verification.
Complete Part 1basedon information currently available. If additional research or investigation would beneeded to fully respond to
any item, please answer as thoroughly aspossible basedoncurrent information; indicatewhether missing informationdoesnot exist,
or is notreasonably available to the sponsor;and,whenpossible, generally describeworkor studieswhichwould be necessaryto
updateor fully developthat information.
Applicants/sponsors must complete all items in SectionsA & B. InSectionsC, D & E,most items contain an initial question that
must be answered either“Yes”or “No”.If the answer tothe initial question is“Yes”, complete the sub-questions thatfollow. If the
answer to the initial question is “No”,proceedto thenextquestion.Section F allows the project sponsor to identify and attach any
additional information. Section G requires thename and signatureof theproject sponsor toverify that the information
contained inPart1is accurate and complete.
A.Project and SponsorInformation.
Name of Action or Project:
õÊ×ÛÈ ÷ÉÙÛÌ× ûÏÇÉ×Ï×ÎÈ ìÛÊÑ õÐ×Î ðÛÑ× úÊÍÍÑ éÈÛÚÓÐÓÂÛÈÓÍÎ
Project Location (describe, and attach a general location map):
õÐ×Î ðÛÑ× úÊÍÍÑ ÅÓÈÔÓÎ ÈÔ× õÊ×ÛÈ ÷ÉÙÛÌ× ûÏÇÉ×Ï×ÎÈ ìÛÊÑ
Brief Description of Proposed Action (include purpose or need):
èÔÓÉ ÌÊÍÒ×ÙÈ ÓÎÙÐÇØ×É ÈÔ× Ê×ÌÛÓÊÓÎÕ ÛÎØ ÉÈÛÚÓÐÓÂÓÎÕ ÍÖ ×ÓÕÔÈ Ê×ÛÙÔ×É ÍÖ ÖÛÓÐÓÎÕ ÉÈÊ×ÛÏ ÚÛÎÑÉ ÅÓÈÔÓÎ õÐ×Î ðÛÑ× úÊÍÍÑ ÓÎ ÈÔ× èÍÅÎ ÍÖ ëÇ××ÎÉÚÇÊà åÛÊÊ×Î
ùÍÇÎÈà î×Å ãÍÊÑ èÔ× ×ÊÍÉÓÍÎ ÍÙÙÇÊÊÓÎÕ ÛÈ ÈÔ×É× ÓØ×ÎÈÓÖÓ×Ø Ê×ÛÙÔ×É ÓÉ ØÇ× ÈÍ ÐÛÙÑ ÍÖ ÚÛÎÑ Æ×Õ×ÈÛÈÓÍÎ ÛÎØ ÛÊÏÍÊÓÎÕ ÛÎØ ÓÉ Û ÙÍÎÈÊÓÚÇÈÓÎÕ ÖÛÙÈÍÊ ÈÍ
É×ØÓÏ×ÎÈÛÈÓÍÎ ÍÖ ÈÔ× ÅÛÈ×ÊÅÛà èÔ× õÊ×ÛÈ ÷ÉÙÛÌ× ìÊÍÌ×ÊÈÓ×É ÓÉ É××ÑÓÎÕ ÈÍ Ê×ÌÛÓÊ ÈÔ×É× ×ÊÍØÓÎÕ ÉÈÊ×ÛÏ ÚÛÎÑÉ ÈÍ ÌÊ×Æ×ÎÈ ÖÇÊÈÔ×Ê É×ØÓÏ×ÎÈÛÈÓÍÎ ÅÔÓÙÔ ÔÛÉ
Ú××Î ÌÊ×Æ×ÎÈÓÎÕ ÌÛÉÉÛÕ× ÖÍÊ ÈÔ×ÓÊ ÉÅÛÎ ÚÍÛÈ ÛÏÇÉ×Ï×ÎÈ ÊÓØ× ÷ÛÙÔ Ê×ÛÙÔ ÅÓÐÐ Ê×ËÇÓÊ× ÈÔ× ÌÐÛÙ×Ï×ÎÈ ÍÖ ÖÓÐÐ Ú×ÐÍÅ ÈÔ× íÊØÓÎÛÊà ôÓÕÔ åÛÈ×Ê ÷Ð×ÆÛÈÓÍÎ
íôå÷ ÍÖ õÐ×Î ðÛÑ× úÊÍÍÑ óÎ Õ×Î×ÊÛÐ ÈÔ× ÚÛÎÑÉ ÅÓÐÐ Ú× Ê×ÕÊÛØ×Ø ÛÎØ ÊÍÙÑ ÛÊÏÍÊÓÎÕ ÅÓÐÐ Ú× ÓÎÉÈÛÐÐ×Ø ÓÎ ÉÇÌÌÍÊÈ ÍÖ Û ÐÍÎÕÈ×ÊÏ Æ×Õ×ÈÛÈÓÍÎ ×ÉÈÛÚÐÓÉÔÏ×ÎÈ
ùÍÓÊ ÐÍÕÉ ÅÓÐÐ Ú× ÇÈÓÐÓÂ×Ø ÛÈ ÈÔ× ÚÛÎÑ
íôå÷ ÓÎÈ×ÊÉ×ÙÈÓÍÎ ÈÍ ÛÐÐÍÅ ÖÍÊ ÈÔ× Æ×Õ×ÈÛÈÓÍÎ ÈÍ ÈÛÑ× ÊÍÍÈ èÔ× ÚÛÎÑ ÉÐÍÌ×É ÅÓÐÐ Ú× ÕÊÛØ×Ø ÈÍ ÊÛÈÓÍÉ ÈÔÛÈ ÅÓÐÐ ÊÛÎÕ×
Ú×ÈÅ××Î
ÛÎØ
Ø×Ì×ÎØ×ÎÈ ÍÎ ÈÔ× ÉÌ×ÙÓÖÓÙ ÙÍÎØÓÈÓÍÎÉ ÍÖ ÈÔ× ÉÈÊ×ÛÏ ÚÛÎÑ ûØØÓÈÓÍÎÛÐÐà ÙÔÛÎÎ×Ð ØÊ×ØÕÓÎÕ ÓÉ ÌÐÛÎÎ×Ø ÈÍ Ê×ÉÈÍÊ× ÈÔ× ÚÊÍÍÑ ÈÍ ÍÊÓÕÓÎÛÐ
Ø×ÌÈÔ ÛÎØ ÛÐÐÍÅ ÖÍÊ ÙÍÎÈÓÎÇ×Ø ÇÉ× ÍÖ ÈÔ× éÅÛÎ úÍÛÈ êÓØ×
Name of Applicant/Sponsor: Telephone:
èÔ× õÊ×ÛÈ ÷ÉÙÛÌ× ìÊÍÌ×ÊÈÓ×É ù
í ê×Ú×ÙÙÛ åÍÍØ ìÛÊÑ ìÊ×ÉÓØ×ÎÈ
E-Mail:
Address:
éÈÛÈ× êÍÇÈ×
City/PO: State:Zip Code:
ëÇ××ÎÉÚÇÊÃ
îã
Project Contact (if not same as sponsor; give name and title/role): Telephone:
éÈ×ÌÔ×Î ð×ö×ÆÊ× ìÊÍÒ×ÙÈ ïÛÎÛÕ×Ê
E-Mail:
ÉÐ×Ö×ÆÊ×üÚÛÊÈÍÎÛÎØÐÍÕÇÓØÓÙ×ÙÍÏ
Address:
ûÓÊÐÓÎ× øÊÓÆ×
City/PO:State: ZipCode:
ûÐÚÛÎÃîã
Property Owner (if not same as sponsor): Telephone:
E-Mail:
Address:
City/PO:State: ZipCode:
Page 1 of 13
ÚÛßÚ îðïç
B.Government Approvals
B.Government Approvals Funding, orSponsorship.
(“Funding” includesgrants, loans, taxrelief,and anyotherforms of financial
assistance.)
Government Entity If Yes: Identify Agency and Approval(s) Application Date
Required
(Actual or projected)
a.CityTown,Yes No
èÍÅÎ ÍÖ ëÇ××ÎÉÚÇÊà èÍÅÎ úÍÛÊØ
or Village Board of Trustees
b.City, Town or Village Yes No
éÓÈ× ìÐÛÎ ûÌÌÊÍÆÛÐ
èÍÅÎ ÍÖ ëÇ××ÎÉÚÇÊà ìÐÛÎÎÓÎÕ úÍÛÊØ
Planning Board or Commission
c.City Townor Yes No
Village Zoning Board of Appeals
d.Other local agencies Yes No
e.County agencies Yes No
f.Regional agencies Yes No
g. State agencies Yes No
îãéø÷ù
h.Federal agencies Yes No
çéûù÷
i.Coastal Resources.
[[195,1301,245,1349][10][,I,][Times New Roman]]i [[206,1301,256,1349][10][,,][Times New Roman]]. [[248,1301,350,1349][10][,,][Times New Roman]]Is th [[321,1301,371,1349][10][,,][Times
New Roman]]e [[349,1301,679,1349][10][,,][Times New Roman]]project site within [[661,1301,711,1349][10][,,][Times New Roman]]a [[690,1301,1245,1349][10][,,][Times New Roman]]Coastal
Area, or the waterfront [[1206,1301,1285,1349][10][,,][Times New Roman]] ar [[1249,1301,1367,1349][10][,,][Times New Roman]]ea of [[1342,1301,1570,1349][10][,,][Times New Roman]]a Designate
[[1538,1301,1588,1349][10][,,][Times New Roman]]d [[1569,1301,1705,1349][10][,,][Times New Roman]]Inland [[1676,1301,1794,1349][10][,,][Times New Roman]] Wat [[1756,1301,1908,1349][10][,,][Times
New Roman]]erway? [[2157,1301,2256,1349][10][,,][Times New Roman]]Yes [[2260,1301,2371,1349][10][,,][Times New Roman]] No
[[184,1397,246,1445][10][,I,][Times New Roman]]ii [[207,1397,257,1445][10][,,][Times New Roman]]. [[249,1397,351,1445][10][,,][Times New Roman]]Is th [[322,1397,372,1445][10][,,][Times
New Roman]]e [[350,1397,694,1445][10][,,][Times New Roman]]project site located [[676,1397,1051,1445][10][,,][Times New Roman]]in a community with [[1022,1397,1101,1445][10][,,][Times
New Roman]] an [[1082,1397,1266,1445][10][,,][Times New Roman]]approved [[1237,1397,1323,1445][10][,,][Times New Roman]] Lo [[1294,1397,1381,1445][10][,,][Times New Roman]]cal [[1352,1397,1807,1445]
[10][,,][Times New Roman]]Waterfront Revitalization [[1779,1397,1897,1445][10][,,][Times New Roman]] Prog [[1868,1397,1982,1445][10][,,][Times New Roman]]ram? [[2151,1397,2276,1445][10][,,][Times
New Roman]] Yes [[2265,1397,2376,1445][10][,,][Times New Roman]] No
[[174,1445,247,1493][10][,I,][Times New Roman]]iii [[208,1445,827,1493][10][,,][Times New Roman]].Is the project site within a Coasta [[795,1445,1218,1493][10][,,][Times New Roman]]l
Erosion Hazard Area? [[2151,1445,2276,1493][10][,,][Times New Roman]] Yes [[2265,1445,2376,1493][10][,,][Times New Roman]] No
C.Planning and Zoning
C.1. Planning and zoning actions.
Will administrative or legislative adoption, or amendment of a plan, local law, ordinance, rule or regulation be the Yes No
only approval(s) which must be granted to enable the proposed action to proceed?
If Yes,
complete sections C, F and G.
If No,
proceed to question C.2 and complete all remaining sections and questions in Part 1
C.2. Adopted land use plans.
a.Do any municipally- adopted (city, town, village or county) comprehensive land use plan(s) include the site Yes No
where the proposed action would be located?
If Yes, does the comprehensive plan include specific recommendations for the site where the proposed action Yes No
would be located?
b.Is the siteof theproposed actionwithin anylocal orregional special planning district(for example:Greenway Yes No
Brownfield Opportunity Area (BOA); designated State or Federal heritage area; watershed management plan;
or other?)
If Yes, identify the plan(s):
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
c.Is the proposed action located wholly or partially within an area listed in an adopted municipal open space plan, Yes No
or an adopted municipal farmland protection plan?
If Yes, identify the plan(s):
________________________________________________________________________________________________________
èÍÅÎ ÍÖ ëÇ××ÎÉÚÇÊà íÌ×Î éÌÛÙ× æÓÉÓÍÎ ìÐÛÎ òÇÎ×
éÓÈ× ÓÉ ÐÓÉÈ×Ø ÓÎ
C.3. Zoning
a.Is the site of the proposed action located in a municipality with an adopted zoning law or ordinance. Yes No
If Yes, what is the zoning classification(s) including any applicable overlay district?
_________________________________________________________________________________________________________
ùÍÏÏ×ÊÙÓÛÐ ïÓÄ×Ø çÉ× ô×ÛÆà ÛÎØ ïÍØ×ÊÛÈ× ê×ÉÓØ×ÎÈÓÛÐ
_________________________________________________________________________________________________________
b.Is the use permitted or allowed by a special or conditional use permit? Yes No
c.Is a zoning change requested as part of the proposed action? Yes No
If Yes,
[[167,584,229,632][10][,I,][Times New Roman]]i. [[199,584,2420,632][10][,,][Times New Roman]]What is the proposed new zoning for the site? __________________________________________________________
_________
C.4. Existing community services.
a.In what school district is the project site located? ________________________________________________________________
ëÇ××ÎÉÚÇÊà çÎÓÍÎ öÊ×× éÙÔÍÍÐ øÓÉÈÊÓÙÈ
b.What police or other public protection forces serve the project site?
_________________________________________________________________________________________________________
î×Å ãÍÊÑ éÈÛÈ× ìÍÐÓÙ× èÊÍÍÌ õ
c.Which fire protection and emergency medical services serve the project site?
__________________________________________________________________________________________________________
ëÇ××ÎÉÚÇÊà ù×ÎÈÊÛÐ
ÖÓÊ× ØÓÉÈÊÓÙÈ ÛÎØ å×ÉÈ õÐ×ÎÉ öÛÐÐÉ ÷ïé
d.What parks serve the project site?
__________________________________________________________________________________________________________
õÐ×Î ðÛÑ× ùÛÎÍ× ðÛÇÎÙÔ
__________________________________________________________________________________________________________
D.Project Details
D.1. Proposed and Potential Development
a.What is the general nature of the proposed action (e.g., residential, industrial, commercial, recreational; if mixed, include all
components)?
ùÍÏÏ×ÊÙÓÛÐ ÛÎØ Ê×ÙÊ×ÛÈÓÍÎÛÐ
_________________________________________________________________________________________________________
b.a. Total acreage of the site of the proposed action?_____________ 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?_____________ acres
c.Is the proposed action an expansion of an existing project or use? Yes No
[[192,1914,254,1962][10][,I,][Times New Roman]]i. [[224,1914,930,1962][10][,,][Times New Roman]]If Yes, what is the approximate percenta [[898,1914,1669,1962][10][,,][Times New Roman]]ge
of the proposed expansion and identify th [[1640,1914,2330,1962][10][,,][Times New Roman]]e units (e.g., acres, miles, housing units [[2297,1914,2347,1962][10][,,][Times New Roman]],
square feet)? % ____________________ Units: ____________________
d.Is the proposed action a subdivision, or does it include a subdivision? Yes No
If Yes,
[[182,2125,244,2173][10][,I,][Times New Roman]]i. [[214,2125,1040,2173][10][,,][Times New Roman]]Purpose or type of subdivision? (e.g., residentia [[1009,2125,1868,2173][10][,,][Times
New Roman]]l, industrial, commercial; if mixed, specify types)
________________________________________________________________________________________________________
[[171,2221,244,2269][10][,I,][Times New Roman]]ii. [[204,2221,947,2269][10][,,][Times New Roman]] Is a cluster/conservation layout proposed? [[2138,2221,2263,2269][10][,,][Times New
Roman]] Yes [[2252,2221,2363,2269][10][,,][Times New Roman]] No
[[161,2269,246,2317][10][,I,][Times New Roman]]iii. [[216,2269,888,2317][10][,,][Times New Roman]]Number of lots proposed? ________
[[171,2317,251,2365][10][,I,][Times New Roman]]iv. [[222,2317,1825,2365][10][,,][Times New Roman]]Minimum and maximum proposed lot sizes? Minimum __________ Maximum __________
Willproposed actionbe constructed in multiple phases? Yes No
If No, anticipatedperiod of construction: _____ months
IfYes:
Total numberof phases anticipated _____
Anticipated commencement date ofphase 1(includingdemolition) _____ month _____ year
Anticipated completiondateof finalphase _____ month _____year
Generally describe connections or relationships among phases, including any contingencies where progress of one phase may
determine timing or duration of future phases: _______________________________________________________________
____________________________________________________________________________________________________
÷ÓÕÔÈ Ê×ÛÙÔ×É ÍÖ ÉÈÊ×ÛÏ Å×Ê× ÛÉÉ×ÉÉ×Ø øÇÊÓÎÕ ìÔÛÉ× ó ÈÔÊ×× ÍÖ ÈÔ×É× Ê×ÛÙÔ×É ÅÓÐÐ Ú× ÉÈÛÚÓÐÓÂ×Ø ûØØÓÈÓÍÎÛÐ ÌÔÛÉ×É ÅÓÐÐ Ú× ÙÍÏÌÐ×È×Ø ÛÉ ÖÇÎØÓÎÕ Ú×ÙÍÏ×É
____________________________________________________________________________________________________
ÛÆÛÓÐÛÚÐ× ÛÎØ ÅÓÐÐ ÓÎÙÐÇØ× ÈÔ× Ê×ÏÛÓÎØ×Ê ÍÖ ÈÔ× ÉÓÈ×É
Page 3 of 13
f.Does the project include new residential uses? YesNo
If Yes, show numbers of units proposed.
One Family Two Family Three Family Multiple Family (four or more)
Initial Phase ___________ ___________ ____________ ________________________
At completion
of all phases ___________ ___________ ____________ ________________________
g.Does the proposed action include new non-residential construction (including expansions)? Yes No
If Yes,
[[181,532,231,580][10][,I,][Times New Roman]]i [[193,532,926,580][10][,,][Times New Roman]].Total number of structures ___________
[[171,580,244,628][10][,I,][Times New Roman]]ii. [[215,580,2023,628][10][,,][Times New Roman]]Dimensions (in feet) of largest proposed structure: ________height; ________width; and
_______ length
[[161,627,246,675][10][,I,][Times New Roman]]iii. [[216,627,1056,675][10][,,][Times New Roman]]Approximate extent of building space to be heat [[1018,627,1296,675][10][,,][Times New
Roman]]ed or cooled: [[1256,627,1577,675][10][,,][Times New Roman]]______________ [[1548,627,1945,675][10][,,][Times New Roman]]________ square feet
h.Does the proposed action include construction or other activities that will result in the impoundment of any Yes No
liquids, such as creation of a water supply, reservoir, pond, lake, waste lagoon or other storage?
If Yes,
[[171,842,233,890][10][,I,][Times New Roman]]i. [[203,842,2414,890][10][,,][Times New Roman]]Purpose of the impoundment: _____________________________________________________________________________
___
[[160,890,233,938][10][,I,][Times New Roman]]ii. [[204,890,1434,938][10][,,][Times New Roman]]If a water impoundment, the principal source of the water: [[1423,890,1735,938][10][
,,][Times New Roman]] Ground water [[1722,890,2161,938][10][,,][Times New Roman]] Surface water streams [[2149,890,2435,938][10][,,][Times New Roman]] Other specify:
_________________________________________________________________________________________________________
[[150,986,235,1034][10][,I,][Times New Roman]]iii. [[205,986,1675,1034][10][,,][Times New Roman]]If other than water, identify the type of impounded/contained liquids and their source.
_________________________________________________________________________________________________________
[[160,1082,240,1130][10][,I,][Times New Roman]]iv. [[211,1082,1202,1130][10][,,][Times New Roman]]Approximate size of the proposed impoundment. Vo [[1173,1082,1578,1130][10][,,][Times
New Roman]]lume: ____________ [[1539,1082,2011,1130][10][,,][Times New Roman]]million gallons; surface ar [[1975,1082,2440,1130][10][,,][Times New Roman]]ea: ____________ acres
[[171,1130,240,1178][10][,I,][Times New Roman]]v. [[210,1130,1851,1178][10][,,][Times New Roman]]Dimensions of the proposed dam or impounding structure: ________ height; _______
length
[[160,1177,240,1225][10][,I,][Times New Roman]]vi. [[211,1177,938,1225][10][,,][Times New Roman]]Construction method/materials for the pr [[902,1177,1436,1225][10][,,][Times New Roman]]oposed
dam or impounding st [[1397,1177,1847,1225][10][,,][Times New Roman]]ructure (e.g., earth fill, ro [[1818,1177,2197,1225][10][,,][Times New Roman]]ck, wood, concrete):
________________________________________________________________________________________________________
D.2. Project Operations
a.Does the proposed action include any excavation, mining, or dredging, during construction, operations, or both? Yes No
(Not including general site preparation, grading or installation of utilities or foundations where all excavated
materials will remain onsite)
If Yes:
[[171,1595,243,1643][10][,I,][Times New Roman]]i . [[203,1595,2438,1643][10][,,][Times New Roman]]What is the purpose of the excavation or dredging? _________________________________________________
______________
ê×ÉÈÍÊ× ÉÈÊ×ÛÏ ÙÔÛÎÎ×Ð ÚÛÉ× ×Ð×ÆÛÈÓÍÎ
[[150,1646,223,1694][10][,I,][Times New Roman]]ii. [[194,1646,1898,1694][10][,,][Times New Roman]]How much material (including rock, earth, sediments, etc.) is proposed to be removed
from the site?
Volume (specify tons or cubic yards): ____________________________________________
ÙÇÚÓÙ ÃÛÊØÉ
Over what duration of time? ____________________________________________________
çÎÑÎÍÅÎ
[[150,1796,235,1844][10][,I,][Times New Roman]]iii. [[206,1796,2263,1844][10][,,][Times New Roman]]Describe nature and characteristics of materials to be excavated or dredged, and plans
to use, manage or dispose of them.
________________________________________________________________________________________________________
éÓÐÈà É×ØÓÏ×ÎÈÉ ÈÍ Ú× ÌÇÏÌ×Ø ÈÔ× ÈÔ× õÊ×ÛÈ ÷ÉÙÛÌ×É ÍÎ ÉÓÈ× ÕÊÛÆ×Ð ÌÓÈ ÆÓÛ ÖÍÊÙ× ÏÛÓÎ
________________________________________________________________________________________________________
i[[182,1940,251,1988][10][,I,][Times New Roman]]v. [[222,1940,1413,1988][10][,,][Times New Roman]]Will there be onsite dewatering or processing of excavated materials? [[2153,1940,2278,1988][10][,,][
Times New Roman]] Yes [[2267,1940,2357,1988][10][,,][Times New Roman]] No
If yes, describe. ___________________________________________________________________________________________
ø×ÅÛÈ×Ê×Ø ÛÈ ØÓÉÙÔÛÊÕ× ÉÓÈ× ÈÔÊÍÇÕÔ ÐÛÊÕ× ÖÓÐÈ×Ê ÚÛÕÉ
________________________________________________________________________________________________________
[[171,2095,240,2143][10][,I,][Times New Roman]]v. [[210,2095,1953,2143][10][,,][Times New Roman]]What is the total area to be dredged or excavated? _____________________________________acres
[[161,2143,241,2191][10][,I,][Times New Roman]]vi. [[211,2143,1959,2191][10][,,][Times New Roman]]What is the maximum area to be worked at any one time? _______________________________
acres
[[150,2195,241,2243][10][,I,][Times New Roman]]vii. [[212,2195,1932,2243][10][,,][Times New Roman]]What would be the maximum depth of excavation or dredging? __________________________
feet
[[150,2242,253,2290][10][,I,][Times New Roman]]viii. [[224,2242,871,2290][10][,,][Times New Roman]]Will the excavation require blasting? [[2143,2242,2269,2290][10][,,][Times New Roman]]
Yes [[2256,2242,2367,2290][10][,,][Times New Roman]] No
[[150,2293,230,2341][10][,I,][Times New Roman]]ix. [[201,2293,2406,2341][10][,,][Times New Roman]]Summarize site reclamation goals and plan: __________________________________________________________
___________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
b.Would the proposed action cause or result in alteration of, increase or decrease in size of, or encroachment Yes No
into any existing wetland, waterbody, shoreline, beach or adjacent area?
If Yes:
[[182,2656,244,2704][10][,I,][Times New Roman]]i. [[214,2656,2368,2704][10][,,][Times New Roman]]Identify the wetland or waterbody which would be affected (by name, water index number,
wetland map number or geographic
description): ______________________________________________________________________________________________
õÐ×Î ðÛÑ× úÊÍÍÑ
[[212,2752,2430,2800][10][,I,][Times New Roman]]_________________________________________________________________________________________________________
Page 4 of 13
[[171,79,244,127][10][,I,][Times New Roman]]ii. [[215,79,395,127][10][,,][Times New Roman]]Describe [[363,79,444,127][10][,,][Times New Roman]] ho [[415,79,517,127][10][,,][Times New
Roman]]w th [[488,79,538,127][10][,,][Times New Roman]]e [[517,79,709,127][10][,,][Times New Roman]] proposed [[680,79,822,127][10][,,][Times New Roman]] action [[803,79,936,127][10][,,][Times
New Roman]]would [[907,79,968,127][10][,,][Times New Roman]] a [[936,79,1124,127][10][,,][Times New Roman]]ffect that [[1095,79,1300,127][10][,,][Times New Roman]]waterbody [[1281,79,1352,127][10][,
,][Times New Roman]]or [[1316,79,1467,127][10][,,][Times New Roman]] wetlan [[1438,79,1488,127][10][,,][Times New Roman]]d [[1459,79,1509,127][10][,,][Times New Roman]], [[1480,79,1659,127][10][,,][T
imes New Roman]]e.g. exca [[1625,79,1739,127][10][,,][Times New Roman]]vatio [[1710,79,1781,127][10][,,][Times New Roman]]n, [[1751,79,2073,127][10][,,][Times New Roman]]fill, placement
of [[2047,79,2189,127][10][,,][Times New Roman]]structu [[2161,79,2301,127][10][,,][Times New Roman]]res, or
alterationof channels,banks and shorelines.Indicate extent ofactivities, alterations and additions insquare feetor acres:
_________________________________________________________________________________________________________
èÔ× ÉÔÍÊ×ÐÓÎ× ÅÓÐÐ Ú× ÉÈÛÚÓÐÓÂ×Ø ÅÓÈÔ ÉÍÏ× ÌÐÛÙ×Ï×ÎÈ ÍÖ ÖÓÐÐ Ú×ÐÍÅ ÈÔ× ÅÛÈ×ÊÐÓÎ× ÛÈ ÈÔ× ÈÍ× ÍÖ ÉÐÍÌ× èÔÓÉ ÅÓÐÐ ÓÎÙÐÇØ× Ê×ÕÊÛØÓÎÕ ÛÉ Å×ÐÐ ÛÉ
_________________________________________________________________________________________________________
ÌÐÛÙ×Ï×ÎÈ ÍÖ ÊÍÙÑ ÛÎØ Æ×Õ×ÈÛÈÓÍÎ
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
[[160,367,245,415][10][,I,][Times New Roman]]iii.
Willproposed action cause or result in disturbance tobottom sediments?YesNo
If Yes,describe:__________________________________________________________________________________________
úÍÈÈÍÏ É×ØÓÏ×ÎÈÉ ÅÓÐÐ Ú× ×ÄÙÛÆÛÈ×Ø
[[172,463,252,511][10][,I,][Times New Roman]]iv. [[222,463,272,511][10][,,][Times New Roman]]W [[262,463,335,511][10][,,][Times New Roman]]ill [[368,463,550,511][10][,,][Times New Roman]]proposed
[[520,463,730,511][10][,,][Times New Roman]] action cau [[701,463,796,511][10][,,][Times New Roman]]se o [[767,463,1212,511][10][,,][Times New Roman]]r result in the destruction [[1183,463,1243,511]
[10][,,][Times New Roman]] o [[1214,463,1395,511][10][,,][Times New Roman]]r remova [[1363,463,1413,511][10][,,][Times New Roman]]l [[1385,463,1456,511][10][,,][Times New Roman]]of [[1420,463,1520,51
1][10][,,][Times New Roman]] aqu [[1490,463,1784,511][10][,,][Times New Roman]]atic vegetation? [[2153,463,2262,511][10][,,][Times New Roman]] Yes [[2267,463,2378,511][10][,,][Times
New Roman]] No
IfYes:
a ofvegetation proposedto be removed ___________________________________________________________
acreageof aquatic vegetation remaining after project completion________________________________________
purpose of proposed removal (e.g. beach clearing, invasive species control, boat access): ____________________________
____________________________________________________________________________________________________
proposed method of plant removal: ________________________________________________________________________
if chemical/herbicide treatment will be used, specify product(s): _________________________________________________
[[171,861,240,909][10][,I,][Times New Roman]]v. [[210,861,2428,909][10][,,][Times New Roman]]Describe any proposed reclamation/mitigation following disturbance: ______________________________________
___________
_________________________________________________________________________________________________________
c.Will the proposed action use, or create a new demand for water? Yes No
If Yes:
[[182,1075,244,1123][10][,I,][Times New Roman]]i. [[214,1075,1829,1123][10][,,][Times New Roman]]Total anticipated water usage/demand per day: __________________________ gallons/day
[[171,1123,244,1171][10][,I,][Times New Roman]]ii. [[215,1123,1516,1171][10][,,][Times New Roman]]Will the proposed action obtain water from an existing public water supply? [[2153,1123,2278,1171][10
][,,][Times New Roman]] Yes [[2267,1123,2378,1171][10][,,][Times New Roman]] No
If Yes:
Name of district or service area: _________________________________________________________________________
Does the existing public water supply have capacity to serve the proposal? Yes No
Is the project site in the existing district? Yes No
Is expansion of the district needed? Yes No
Do existing lines serve the project site? Yes No
[[161,1495,246,1543][10][,I,][Times New Roman]]iii. [[216,1495,1007,1543][10][,,][Times New Roman]]Will line extension within an existing district [[968,1495,1532,1543][10][,,][Times
New Roman]] be necessary to supply the proj [[1493,1495,1591,1543][10][,,][Times New Roman]]ect? [[2153,1495,2278,1543][10][,,][Times New Roman]] Yes [[2267,1495,2378,1543][10][,,][Times
New Roman]] No
If Yes:
Describe extensions or capacity expansions proposed to serve this project: ________________________________________
____________________________________________________________________________________________________
Source(s) of supply for the district: ________________________________________________________________________
[[171,1766,251,1814][10][,I,][Times New Roman]]iv. [[222,1766,793,1814][10][,,][Times New Roman]]Is a new water supply district or [[756,1766,1188,1814][10][,,][Times New Roman]] service
area proposed t [[1149,1766,1379,1814][10][,,][Times New Roman]]o be formed [[1351,1766,1798,1814][10][,,][Times New Roman]] to serve the project site? [[2153,1766,2278,1814][10][,,][Times
New Roman]] Yes [[2267,1766,2378,1814][10][,,][Times New Roman]] No
If, Yes:
Applicant/sponsor for new district: ________________________________________________________________________
Date application submitted or anticipated: __________________________________________________________________
Proposed source(s) of supply for new district: _______________________________________________________________
[[182,2027,251,2075][10][,I,][Times New Roman]]v. [[221,2027,2416,2075][10][,,][Times New Roman]]If a public water supply will not be used, describe plans to provide water supply for
the project: ___________________________
_________________________________________________________________________________________________________
[[161,2126,230,2174][10][,I,][Times New Roman]]vi [[191,2126,241,2174][10][,,][Times New Roman]]. [[212,2126,276,2174][10][,,][Times New Roman]]If [[250,2126,482,2174][10][,,][Times
New Roman]]water suppl [[442,2126,493,2174][10][,,][Times New Roman]]y [[474,2126,620,2174][10][,,][Times New Roman]]will be [[599,2126,698,2174][10][,,][Times New Roman]]from [[690,2126,987,2174][1
0][,,][Times New Roman]]wells (public or [[951,2126,1058,2174][10][,,][Times New Roman]] priv [[1028,2126,1140,2174][10][,,][Times New Roman]]ate), [[1302,2126,1489,2174][10][,,][Times
New Roman]]maximum [[1471,2126,1531,2174][10][,,][Times New Roman]] p [[1501,2126,1604,2174][10][,,][Times New Roman]]ump [[1575,2126,1657,2174][10][,,][Times New Roman]]ing [[1629,2126,1727,2174][1
0][,,][Times New Roman]] cap [[1697,2126,1975,2174][10][,,][Times New Roman]]acity: _______ [[1956,2126,2253,2174][10][,,][Times New Roman]]gallons/minute.
d. Will the proposed action generate liquid wastes? Yes No
If Yes:
[[171,2308,233,2356][10][,I,][Times New Roman]]i. [[214,2308,1616,2356][10][,,][Times New Roman]]Total anticipated liquid waste generation per day: _______________ gallons/day
[[171,2356,244,2404][10][,I,][Times New Roman]]ii. [[215,2356,2270,2404][10][,,][Times New Roman]]Nature of liquid wastes to be generated (e.g., sanitary wastewater, industrial; if combination,
describe all components and
approximate volumes or proportions of each): __________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
[[150,2547,235,2595][10][,I,][Times New Roman]]iii. [[205,2547,976,2595][10][,,][Times New Roman]]Will the proposed action use any existing pu [[946,2547,1579,2595][10][,,][Times New
Roman]]blic wastewater treatment facilities? [[2143,2547,2269,2595][10][,,][Times New Roman]] Yes [[2257,2547,2347,2595][10][,,][Times New Roman]] No
If Yes:
Name of wastewater treatment plant to be used: _____________________________________________________________
Name of district: ______________________________________________________________________________________
Does the existing wastewater treatment plant have capacity to serve the project? Yes No
Is the project site in the existing district? Yes No
Is expansion of the district needed? Yes No
Page 5 of 13
Do existingsewer lines serve theproject site? Yes No
Willline extensionwithin anexisting districtbenecessary to servetheproject? Yes No
If Yes:
Describe extensions or capacity expansions proposed to serve this project: ____________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
[[150,392,230,440][10][,I,][Times New Roman]]iv. [[201,392,1664,440][10][,,][Times New Roman]]Will a new wastewater (sewage) treatment district be formed to serve the project site? [[2143,392,2269,44
0][10][,,][Times New Roman]] Yes [[2257,392,2368,440][10][,,][Times New Roman]] No
If Yes:
Applicant/sponsor for new district: ____________________________________________________________________
Date application submitted or anticipated: _______________________________________________________________
What is the receiving water for the wastewater discharge? __________________________________________________
[[150,640,219,688][10][,I,][Times New Roman]]v. [[200,640,1188,688][10][,,][Times New Roman]]If public facilities will not be used, describe plans to prov [[1159,640,2265,688][10][,,][Times
New Roman]]ide wastewater treatment for the project, including specifying pr [[2229,640,2376,688][10][,,][Times New Roman]]oposed
receiving water (name and classification if surfacedischargeordescribesubsurface disposalplans):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
[[150,832,230,880][10][,I,][Times New Roman]]vi. [[201,832,2403,880][10][,,][Times New Roman]]Describe any plans or designs to capture, recycle or reuse liquid waste: ________________________________
_______________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
e.Will the proposed action disturb more than one acre and create stormwater runoff, either from new point Yes No
sources (i.e. ditches, pipes, swales, curbs, gutters or other concentrated flows of stormwater) or non-point
source (i.e. sheet flow) during construction or post construction?
If Yes:
[[171,1209,233,1257][10][,I,][Times New Roman]]i. [[203,1209,1108,1257][10][,,][Times New Roman]]How much impervious surface will the project creat [[1070,1209,1805,1257][10][,,][Times
New Roman]]e in relation to total size of project parcel?
_____
Square feetor _____ acres (impervious surface)
_____ Square feet or _____ acres (parcel size)
[[161,1352,234,1400][10][,I,][Times New Roman]]ii. [[204,1352,2409,1400][10][,,][Times New Roman]]Describe types of new point sources. _______________________________________________________________
___________
_________________________________________________________________________________________________________
[[150,1448,235,1496][10][,I,][Times New Roman]]iii. [[205,1448,1220,1496][10][,,][Times New Roman]]Where will the stormwater runoff be directed (i.e. on-site [[1180,1448,2280,1496][10][,,][Times
New Roman]]stormwater management facility/structures, adjacent properties,
groundwater, on-site surface water or off-site surface waters)?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
If to surface waters, identify receiving water bodies or wetlands: ________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Will stormwater runoff flow to adjacent properties? Yes No
[[150,1838,230,1886][10][,I,][Times New Roman]]iv. [[201,1838,321,1886][10][,,][Times New Roman]]Does [[358,1838,540,1886][10][,,][Times New Roman]]proposed [[522,1838,1142,1886][10][,,][Times
New Roman]]plan minimize impervious surfaces [[1107,1838,1157,1886][10][,,][Times New Roman]], [[1128,1838,1199,1886][10][,,][Times New Roman]]us [[1165,1838,1215,1886][10][,,][Times
New Roman]]e [[1194,1838,1372,1886][10][,,][Times New Roman]]pervious [[1338,1838,1398,1886][10][,,][Times New Roman]] m [[1381,1838,1659,1886][10][,,][Times New Roman]]aterials or
coll [[1620,1838,2100,1886][10][,,][Times New Roman]]ect and re-use stormwater? [[2147,1838,2273,1886][10][,,][Times New Roman]] Yes [[2260,1838,2350,1886][10][,,][Times New Roman]]
No
f.Does the proposed action include, or will it use on-site, one or more sources of air emissions, including fuel Yes No
combustion, waste incineration, or other processes or operations?
If Yes, identify:
[[181,2042,231,2090][10][,I,][Times New Roman]]i [[193,2042,1774,2090][10][,,][Times New Roman]].Mobile sources during project operations (e.g., heavy equipment, fleet or delivery vehicles)
_________________________________________________________________________________________________________
éÍÏ× È×ÏÌÍÊÛÊà ÇÉ× ÍÖ Ô×ÛÆà ×ËÇÓÌÏ×ÎÈ
[[171,2138,244,2186][10][,I,][Times New Roman]]ii. [[215,2138,1979,2186][10][,,][Times New Roman]]Stationary sources during construction (e.g., power generation, structural heating,
batch plant, crushers)
________________________________________________________________________________________________________
[[160,2234,245,2282][10][,I,][Times New Roman]]iii. [[216,2234,1839,2282][10][,,][Times New Roman]]Stationary sources during operations (e.g., process emissions, large boilers, electric
generation)
________________________________________________________________________________________________________
g.Will any air emission sources named in D.2.f (above), require a NY State Air Registration, Air Facility Permit, Yes No
or Federal Clean Air Act Title IV or Title V Permit?
If Yes:
[[150,2492,212,2540][10][,I,][Times New Roman]]i. [[193,2492,1156,2540][10][,,][Times New Roman]]Is the project site located in an Air quality non-attainme [[1124,2492,2041,2540][10][,,][Times
New Roman]]nt area? (Area routinely or periodically fails to meet [[2143,2492,2269,2540][10][,,][Times New Roman]] Yes [[2256,2492,2367,2540][10][,,][Times New Roman]] No
ambient air quality standards for all or some parts of the year)
[[150,2588,223,2636][10][,I,][Times New Roman]]ii. [[194,2588,1593,2636][10][,,][Times New Roman]]In addition to emissions as calculated in the application, the project will generate:
___________Tons/year ()of CarbonDioxide (CO)
2
___________Tons/year() of NitrousOxide (N)
2
___________Tons/year() of Perfluorocarbons (PFCs)
___________Tons/year() of Sulfur Hexafluoride (SF)
6
___________Tons/year ()of CarbonDioxide equivalent ofHydroflorocarbons (H)
___________Tons/year ()ofHazardous Air Pollutants (HAPs)
Page 6 of 13
h.Will the proposed action generate or emit methane (including, but not limited to, sewage treatment plants, Yes No
landfills, composting facilities)?
If Yes:
[[171,223,233,271][10][,I,][Times New Roman]]i. [[203,223,2422,271][10][,,][Times New Roman]]Estimate methane generation in tons/year (metric): _______________________________________________________
_________
[[161,271,223,319][10][,I,][Times New Roman]]ii [[184,271,2334,319][10][,,][Times New Roman]].Describe any methane capture, control or elimination measures included in project design
(e.g., combustion to generate heat o [[2305,271,2355,319][10][,,][Times New Roman]]r
electricity, flaring): ________________________________________________________________________________________
_________________________________________________________________________________________________________
i.Will the proposed action result in the release of air pollutants from open-air operations or processes, such as Yes No
quarry or landfill operations?
If Yes: Describe operations and nature of emissions (e.g., diesel exhaust, rock particulates/dust):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
j.Will the proposed action result in a substantial increase in traffic above present levels or generate substantial Yes No
new demand for transportation facilities or services?
If Yes:
[[181,861,243,909][10][,I,][Times New Roman]]i. [[214,861,1207,909][10][,,][Times New Roman]]When is the peak traffic expected (Check all that apply): [[1252,861,1405,909][10][,,][Times
New Roman]] Morni [[1367,861,1438,909][10][,,][Times New Roman]]ng [[1552,861,1751,909][10][,,][Times New Roman]] Evening [[1852,861,2039,909][10][,,][Times New Roman]]Weekend
Randomly between hours of __________ to ________.
[[181,957,254,1005][10][,I,][Times New Roman]]ii. [[225,957,939,1005][10][,,][Times New Roman]]For commercial activities only, projected [[920,957,1065,1005][10][,,][Times New Roman]]numbe
[[1033,957,1083,1005][10][,,][Times New Roman]]r [[1057,957,1354,1005][10][,,][Times New Roman]]of truck trips/da [[1322,957,1373,1005][10][,,][Times New Roman]]y
Parking spaces:Existing_____________
Proposed___________Netincrease/decrease_____________
[[172,1193,241,1241][10][,I,][Times New Roman]]v.
[[150,1292,230,1340][10][,I,][Times New Roman]]vi. [[211,1292,305,1340][10][,,][Times New Roman]]Are [[284,1292,786,1340][10][,,][Times New Roman]]public/private transportation [[757,1292,866,1340][1
0][,,][Times New Roman]] serv [[837,1292,966,1340][10][,,][Times New Roman]]ice(s) [[939,1292,1010,1340][10][,,][Times New Roman]]or [[985,1292,1035,1340][10][,,][Times New Roman]]f
[[998,1292,1308,1340][10][,,][Times New Roman]]acilities availabl [[1270,1292,1320,1340][10][,,][Times New Roman]]e [[1298,1292,1401,1340][10][,,][Times New Roman]]with [[1372,1292,1434,1340][10][,,
][Times New Roman]]in [[1415,1292,1612,1340][10][,,][Times New Roman]]½ mile of [[1576,1292,1648,1340][10][,,][Times New Roman]] th [[1619,1292,1919,1340][10][,,][Times New Roman]]e
proposed site? [[2143,1292,2269,1340][10][,,][Times New Roman]] Yes [[2257,1292,2368,1340][10][,,][Times New Roman]] No
[[150,1340,230,1388][10][,I,][Times New Roman]]vii [[212,1340,379,1388][10][,,][Times New Roman]]Will the [[358,1340,540,1388][10][,,][Times New Roman]]proposed [[522,1340,946,1388][10][,,][Times
New Roman]]action include access to [[926,1340,1062,1388][10][,,][Times New Roman]]public [[1041,1340,1135,1388][10][,,][Times New Roman]]tran [[1106,1340,1354,1388][10][,,][Times New
Roman]]sportation or [[1328,1340,1486,1388][10][,,][Times New Roman]]accomm [[1469,1340,1644,1388][10][,,][Times New Roman]]odations [[1621,1340,1730,1388][10][,,][Times New Roman]]for
u [[1700,1340,1766,1388][10][,,][Times New Roman]]se [[1745,1340,1816,1388][10][,,][Times New Roman]]of [[1790,1340,2074,1388][10][,,][Times New Roman]]hybrid, electric [[2143,1340,2269,1388][10][,,
][Times New Roman]] Yes [[2257,1340,2368,1388][10][,,][Times New Roman]] No
or other alternative fueled vehicles?
No
[[150,1436,241,1484][10][,I,][Times New Roman]]viii [[203,1436,274,1484][10][,,][Times New Roman]].W [[264,1436,1137,1484][10][,,][Times New Roman]]ill the proposed action include plans
for pedestrian [[1107,1436,1649,1484][10][,,][Times New Roman]] or bicycle accommodations fo [[1621,1436,1916,1484][10][,,][Times New Roman]]r connections to [[1887,1436,2058,1484][10][,,][Times
New Roman]] existing [[2143,1436,2269,1484][10][,,][Times New Roman]] Yes
pedestrian or bicycle routes?
k.Will the proposed action (for commercial or industrial projects only) generate new or additional demand Yes No
for energy?
If Yes:
[[171,1761,233,1809][10][,I,][Times New Roman]]i. [[203,1761,2426,1809][10][,,][Times New Roman]]Estimate annual electricity demand during operation of the proposed action: __________________________
__________________
_________________________________________________________________________________________________________
[[160,1857,233,1905][10][,I,][Times New Roman]]ii. [[204,1857,254,1905][10][,,][Times New Roman]]A [[234,1857,777,1905][10][,,][Times New Roman]]nticipated sources/suppliers of [[741,1857,1462,1905][
10][,,][Times New Roman]] electricity for the project (e.g., on-site co [[1433,1857,2250,1905][10][,,][Times New Roman]]mbustion, on-site renewable, via grid/local util [[2212,1857,2348,1905][10][,,]
[Times New Roman]]ity, or
other):
________________________________________________________________________________________________________
[[150,2000,235,2048][10][,I,][Times New Roman]]iii. [[205,2000,532,2048][10][,,][Times New Roman]]Will the proposed [[503,2000,644,2048][10][,,][Times New Roman]] action [[626,2000,804,2048][10][,,][
Times New Roman]]require a [[783,2000,854,2048][10][,,][Times New Roman]]ne [[822,2000,902,2048][10][,,][Times New Roman]]w, [[873,2000,987,2048][10][,,][Times New Roman]]or an [[967,2000,1132,2048][
10][,,][Times New Roman]]upgrade [[1112,2000,1376,2048][10][,,][Times New Roman]] to an existing [[1346,2000,1444,2048][10][,,][Times New Roman]] sub [[1415,2000,1576,2048][10][,,][Times
New Roman]]station? [[2143,2000,2269,2048][10][,,][Times New Roman]] Yes [[2256,2000,2367,2048][10][,,][Times New Roman]] No
l.Hours of operation. Answer all items which apply.
[[181,2152,243,2200][10][,I,][Times New Roman]]i. [[203,2152,607,2200][10][,,][Times New Roman]] During Construction: [[1215,2152,1288,2200][10][,I,][Times New Roman]]ii. [[1269,2152,1631,2200][10][,
,][Times New Roman]]During Operations:
Monday - Friday: _________________________Monday - Friday: ____________________________
î
û
ÛÌ
Saturday: ________________________________Saturday: ___________________________________
î
û
Sunday: _________________________________Sunday: ____________________________________
î
û
Holidays: ________________________________Holidays: ___________________________________
Page 7 of 13
m.Will the proposed action produce noise that will exceed existing ambient noise levels during construction, Yes No
operation, or both?
If yes:
[[150,223,212,271][10][,I,][Times New Roman]]i. [[193,223,1226,271][10][,,][Times New Roman]]Provide details including sources, time of day and duration:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
[[150,366,212,414][10][,I,][Times New Roman]]ii [[173,366,223,414][10][,,][Times New Roman]]. [[204,366,316,414][10][,,][Times New Roman]]Will [[350,366,532,414][10][,,][Times New Roman]]proposed
[[502,366,644,414][10][,,][Times New Roman]] action [[615,366,675,414][10][,,][Times New Roman]] r [[639,366,740,414][10][,,][Times New Roman]]emo [[710,366,782,414][10][,,][Times New
Roman]]ve [[750,366,829,414][10][,,][Times New Roman]] ex [[800,366,1004,414][10][,,][Times New Roman]]isting natu [[974,366,1056,414][10][,,][Times New Roman]]ral [[1027,366,1189,414][10][,,][Times
New Roman]]barriers [[1166,366,1361,414][10][,,][Times New Roman]]that could [[1342,366,1470,414][10][,,][Times New Roman]]act as [[1446,366,1546,414][10][,,][Times New Roman]]a no
[[1516,366,1594,414][10][,,][Times New Roman]]ise [[1572,366,1623,414][10][,,][Times New Roman]]b [[1593,366,1719,414][10][,,][Times New Roman]]arrier [[1694,366,1765,414][10][,,][Times
New Roman]]or [[1728,366,1874,414][10][,,][Times New Roman]] screen [[1845,366,1895,414][10][,,][Times New Roman]]? [[2143,366,2269,414][10][,,][Times New Roman]] Yes [[2257,366,2368,414][10][,,][T
imes New Roman]] No
Describe: _________________________________________________________________________________________________
_________________________________________________________________________________________________________
n.Willtheproposedactionhaveoutdoorlighting? Yes No
If yes:
Describe source(s), location(s), height of fixture(s), direction/aim, and proximity to nearest occupied structures:
[[165,625,227,673][10][,I,][Times New Roman]]i.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
[[150,768,212,816][10][,I,][Times New Roman]]ii [[173,768,223,816][10][,,][Times New Roman]]. [[204,768,1129,816][10][,,][Times New Roman]]Will proposed action remove existing natural
barriers [[1095,768,1824,816][10][,,][Times New Roman]] that could act as a light barrier or screen? [[2143,768,2269,816][10][,,][Times New Roman]] Yes [[2256,768,2346,816][10][,,][Times
New Roman]] No
Describe: _________________________________________________________________________________________________
_________________________________________________________________________________________________________
o[[171,945,221,993][10][,I,][Times New Roman]]. [[192,945,1790,993][10][,,][Times New Roman]]Does the proposed action have the potential to produce odors for more than one hour per day?
[[2143,945,2269,993][10][,,][Times New Roman]] Yes [[2257,945,2347,993][10][,,][Times New Roman]] No
If Yes, describe possible sources, potential frequency and duration of odor emissions, and proximity to nearest
occupied structures: ______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
p.Will theproposed action include any bulkstorageof petroleum (over1,100gallons) Yes No
or chemical products?
If Yes:
Product(s) to be stored ______________________________________________________________________________________
Volume(s)______perunit time___________(e.g., month, year)
Generally describeproposed storagefacilities________________________________________________________________
________________________________________________________________________________________________________
q.Will the proposed action (commercial, industrial and recreational projects only) use pesticides (i.e., herbicides, Yes No
insecticides) during construction or operation?
If Yes:
Describe proposed treatment(s):
[[192,1723,254,1771][10][,I,][Times New Roman]]i.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
[[180,1962,253,2010][10][,I,][Times New Roman]]ii. [[224,1962,1399,2010][10][,,][Times New Roman]]Will the proposed action use Integrated Pest Management Practices? [[2143,1962,2289,2010][10][,,][Tim
es New Roman]] Yes [[2277,1962,2388,2010][10][,,][Times New Roman]] No
r.Will the proposed action (commercial or industrial projects only) involve or require the management or disposal Yes No
of solid waste (excluding hazardous materials)?
If Yes:
[[181,2157,243,2205][10][,I,][Times New Roman]]i. [[214,2157,1020,2205][10][,,][Times New Roman]]Describe any solid waste(s) to be generated du [[990,2157,1771,2205][10][,,][Times New
Roman]]ring construction or operation of the facility:
Construction: ____________________ tons per ________________ (unit of time)
Operation : ____________________ tons per ________________ (unit of time)
[[171,2307,244,2355][10][,I,][Times New Roman]]ii. [[215,2307,2131,2355][10][,,][Times New Roman]]Describe any proposals for on-site minimization, recycling or reuse of materials to
avoid disposal as solid waste:
Construction: ________________________________________________________________________________________
____________________________________________________________________________________________________
Operation: __________________________________________________________________________________________
____________________________________________________________________________________________________
[[150,2553,235,2601][10][,I,][Times New Roman]]iii. [[205,2553,888,2601][10][,,][Times New Roman]]Proposed disposal methods/facilities fo [[859,2553,1416,2601][10][,,][Times New Roman]]r
solid waste generated on-site:
Construction: ________________________________________________________________________________________
____________________________________________________________________________________________________
Operation: __________________________________________________________________________________________
____________________________________________________________________________________________________
Page 8 of 13
s.Does the proposed action include construction or modification of a solid waste management facility? Yes No
If Yes:
Type of management or handling of waste proposed for the site (e.g., recycling or transfer station, composting, landfill, or
[[181,175,243,223][10][,I,][Times New Roman]]i.
other disposal activities): ___________________________________________________________________________________
[[171,271,244,319][10][,I,][Times New Roman]]ii. [[225,271,924,319][10][,,][Times New Roman]]Anticipated rate of disposal/processing:
________ Tons/month, if transfer or other non-combustion/thermal treatment, or
________ Tons/hour, if combustion or thermal treatment
[[171,420,256,468][10][,I,][Times New Roman]]iii. [[226,420,707,468][10][,,][Times New Roman]]If landfill, anticipated site [[667,420,1543,468][10][,,][Times New Roman]]life: _______________________
_________ years
t.Willproposed action at thesite involve the commercial generation, treatment,storage,ordisposalof hazardous Yes No
waste?
If Yes:
[[181,635,243,683][10][,I,][Times New Roman]]i. [[214,635,879,683][10][,,][Times New Roman]]Name(s) of all hazardous wastes or co [[850,635,1509,683][10][,,][Times New Roman]]nstituents
to be generated, handled or [[1472,635,1863,683][10][,,][Times New Roman]] managed at facility: [[1824,635,2145,683][10][,,][Times New Roman]]______________ [[2116,635,2416,683][10][,,][Times
New Roman]]_____________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
[[171,779,244,827][10][,I,][Times New Roman]]ii. [[215,779,1156,827][10][,,][Times New Roman]]Generally describe processes or activities involving ha [[1124,779,2410,827][10][,,][Times
New Roman]]zardous wastes or constituents: ___________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________
[[171,923,244,971][10][,I,][Times New Roman]]iii [[205,923,1293,971][10][,,][Times New Roman]].Specify amount to be handled or generated _____ tons/month
[[171,971,251,1019][10][,I,][Times New Roman]]iv. [[222,971,1198,1019][10][,,][Times New Roman]]Describe any proposals for on-site minimization, recycli [[1160,971,2414,1019][10][,,][Times
New Roman]]ng or reuse of hazardous constituents: ____________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
[[182,1114,251,1162][10][,I,][Times New Roman]]v. [[221,1114,1013,1162][10][,,][Times New Roman]]Will any hazardous wastes be disposed at an [[973,1114,1414,1162][10][,,][Times New
Roman]]existing offsite hazardou [[1385,1114,1684,1162][10][,,][Times New Roman]]s waste facility? [[2143,1114,2269,1162][10][,,][Times New Roman]] Yes [[2257,1114,2378,1162][10][,,][Times
New Roman]] No
If Yes: provide name and location of facility: _______________________________________________________________________
________________________________________________________________________________________________________
If No: describe proposed management of any hazardous wastes which will not be sent to a hazardous waste facility:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
E.Site and Setting of Proposed Action
E.1. Land uses on and surrounding the project site
a.Existing land uses.
[[198,1664,260,1712][10][,I,][Times New Roman]]i. [[231,1664,1336,1712][10][,,][Times New Roman]]Check all uses that occur on, adjoining and near the project site.
Urban Industrial Commercial Residential (suburban) Rural (non-farm)
Forest Agriculture Aquatic Other (specify): ____________________________________
ûÏÇÉ×Ï×ÎÈ ìÛÊÑ
[[177,1808,250,1856][10][,I,][Times New Roman]]ii. [[232,1808,838,1856][10][,,][Times New Roman]]If mix of uses, generally describe:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
b.Land uses and covertypes on the project site.
Land use or Current Acreage After Change
Covertype Acreage Project Completion (Acres +/-)
Roads, buildings, and other paved or impervious
surfaces
Forested
Meadows, grasslands or brushlands (non-
agricultural, including abandoned agricultural)
Agricultural
(includes active orchards, field, greenhouse etc.)
Surface water features
(lakes, ponds, streams, rivers, etc.)
Wetlands (freshwater or tidal)
Non-vegetated (bare rock, earth or fill)
Other
Describe: _______________________________
________________________________________
Page 9 of 13
c.Is the project site presently used by members of the community for public recreation? Yes No
[[188,128,250,176][10][,I,][Times New Roman]]i. [[220,128,2404,176][10][,,][Times New Roman]]If Yes: explain: ________________________________________________________________________________________
__
èÔ×Ï× ìÛÊÑ êÓØ×
d.Are there any facilities serving children, the elderly, people with disabilities (e.g., schools, hospitals, licensed Yes No
day care centers, or group homes) within 1500 feet of the project site?
If Yes,
[[188,337,250,385][10][,I,][Times New Roman]]i. [[220,337,565,385][10][,,][Times New Roman]]Identify Facilities:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
e.Does the project site contain an existing dam? Yes No
If Yes:
[[188,608,250,656][10][,I,][Times New Roman]]i. [[220,608,970,656][10][,,][Times New Roman]]Dimensions of the dam and impoundment:
Dam height: _________________________________ feet
Dam length: _________________________________ feet
Surface area: _________________________________ acres
Volume impounded: _______________________________ gallons OR acre-feet
[[177,872,250,920][10][,I,][Times New Roman]]ii. [[221,872,320,920][10][,,][Times New Roman]]Dam [[312,872,894,920][10][,,][Times New Roman]]s existing hazard classification: [[854,872,1133,920][10
][,,][Times New Roman]]____________ [[1104,872,1445,920][10][,,][Times New Roman]]_______________ [[1417,872,2196,920][10][,,][Times New Roman]]____________________________________ [[2167,872,2404,92
0][10][,,][Times New Roman]]__________
ã
[[177,920,262,968][10][,I,][Times New Roman]]iii. [[233,920,1171,968][10][,,][Times New Roman]]Provide date and summarize results of last inspection:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
f.Has the project site ever been used as a municipal, commercial or industrial solid waste management facility, Yes No
or does the project site adjoin property which is now, or was at one time, used as a solid waste management facility?
If Yes:
[[188,1237,250,1285][10][,I,][Times New Roman]]i. [[210,1237,884,1285][10][,,][Times New Roman]] Has the facility been formally closed? [[2149,1237,2275,1285][10][,,][Times New Roman]]
Yes [[2263,1237,2384,1285][10][,,][Times New Roman]] No
If yes, cite sources/documentation: _______________________________________________________________________
[[177,1348,250,1396][10][,I,][Times New Roman]]ii. [[221,1348,1084,1396][10][,,][Times New Roman]]Describe the location of the project site relative to [[1054,1348,1259,1396][10][,,][Times
New Roman]] the bound [[1231,1348,2014,1396][10][,,][Times New Roman]]aries of the solid waste management facility:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
[[167,1492,252,1540][10][,I,][Times New Roman]]iii. [[222,1492,2408,1540][10][,,][Times New Roman]]Describe any development constraints due to the prior solid waste activities: ______________________
____________________
_______________________________________________________________________________________________________
g.Have hazardous wastes been generated, treated and/or disposed of at the site, or does the project site adjoin Yes No
property which is now or was at one time used to commercially treat, store and/or dispose of hazardous waste?
If Yes:
[[177,1765,239,1813][10][,I,][Times New Roman]]i. [[209,1765,2158,1813][10][,,][Times New Roman]]Describe waste(s) handled and waste management activities, including approximate time
when activities occurred:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
h.Potential contamination history. Has there been a reported spill at the proposed project site, or have any Yes No
remedial actions been conducted at or adjacent to the proposed site?
If Yes:
[[188,2080,250,2128][10][,I,][Times New Roman]]i. [[220,2080,1850,2128][10][,,][Times New Roman]]Is any portion of the site listed on the NYSDEC Spills Incidents database or Environmental
Site [[2149,2080,2275,2128][10][,,][Times New Roman]] Yes [[2263,2080,2374,2128][10][,,][Times New Roman]] No
Remediation database? Check all that apply:
Yes – Spills Incidents database Provide DEC ID number(s): ________________________________
Yes – Environmental Site Remediation database Provide DEC ID number(s): ________________________________
Neither database
[[156,2346,229,2394][10][,I,][Times New Roman]]ii. [[200,2346,2394,2394][10][,,][Times New Roman]]If site has been subject of RCRA corrective activities, describe control measures:___________________
____________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
[[167,2493,252,2541][10][,I,][Times New Roman]]iii. [[222,2493,1000,2541][10][,,][Times New Roman]]Is the project within 2000 feet of any site in [[961,2493,1949,2541][10][,,][Times
New Roman]]the NYSDEC Environmental Site Remediation database? [[2149,2493,2275,2541][10][,,][Times New Roman]] Yes [[2229,2493,2279,2535][10][,,][Z@R6BE9.tmp]] [[2263,2493,2374,2541][10][,,][Time
s New Roman]] No
If yes, provide DEC ID number(s): ______________________________________________________________________________
[[167,2605,247,2653][10][,I,][Times New Roman]]iv. [[218,2605,831,2653][10][,,][Times New Roman]]If yes to (i), (ii) or (iii) above, desc [[799,2605,914,2653][10][,,][Times New Roman]]ribe
[[874,2605,1305,2653][10][,,][Times New Roman]]current status of site(s):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Page 10 of 13
[[177,80,246,128][10][,I,][Times New Roman]]v. [[216,80,1487,128][10][,,][Times New Roman]]Is the project site subject to an institutional control limiting property uses? [[2149,80,2275,128][10][,,][
Times New Roman]] Yes [[2263,80,2384,128][10][,,][Times New Roman]] No
If yes, DEC site ID number: ____________________________________________________________________________
Describe the type of institutional control (e.g., deed restriction or easement): ____________________________________
Describe any use limitations: ___________________________________________________________________________
Describe any engineering controls: _______________________________________________________________________
Will the project affect the institutional or engineering controls in place? Yes No
Explain: ____________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
E.2. Natural Resources On or Near Project Site
a.What is the average depth to bedrock on the project site? ________________ feet
b. Are there bedrock outcroppings on the project site? Yes No
If Yes, what proportion of the site is comprised of bedrock outcroppings? __________________%
c.Predominant soil type(s) present on project site: ___________________________ __________%
éÛ
___________________________ __________%
ôÎú
____________________________ __________%
íÛú
d.What is the average depth to the water table on the project site? Average: _________ feet
e.Drainage status of project site soils: Well Drained:_____%ofite
Moderately Well Drained: _____% of site
Poorly Drained _____%ofite
f.Approximate proportion of proposed action site with slopes: 0-10%:_____% of site
10-15%: _____% of site
15% or greater: _____% of site
g.Are there any unique geologic features on the project site? Yes No
If Yes, describe: _____________________________________________________________________________________________
________________________________________________________________________________________________________
h.Surface water features.
[[177,1697,239,1745][10][,I,][Times New Roman]]i. [[209,1697,1927,1745][10][,,][Times New Roman]]Does any portion of the project site contain wetlands or other waterbodies (including
streams, rivers, [[2149,1697,2275,1745][10][,,][Times New Roman]] Yes [[2263,1697,2374,1745][10][,,][Times New Roman]] No
ponds or lakes)?
[[167,1793,240,1841][10][,I,][Times New Roman]]ii. [[211,1793,1264,1841][10][,,][Times New Roman]]Do any wetlands or other waterbodies adjoin the project site? [[2149,1793,2275,1841][10][,,][Times
New Roman]] Yes [[2263,1793,2374,1841][10][,,][Times New Roman]] No
If Yes to either [[418,1849,468,1897][10][,I,][Times New Roman]]i [[429,1849,524,1897][10][,,][Times New Roman]] or [[485,1849,547,1897][10][,I,][Times New Roman]]ii [[508,1849,1065,1897][10][,,][Ti
mes New Roman]], continue. If No, skip to E.2.i.
[[156,1905,241,1953][10][,I,][Times New Roman]]iii. [[222,1905,1089,1953][10][,,][Times New Roman]]Are any of the wetlands or waterbodies within or [[1050,1905,1928,1953][10][,,][Times
New Roman]]adjoining the project site regulated by any federal, [[2149,1905,2275,1953][10][,,][Times New Roman]] Yes [[2263,1905,2374,1953][10][,,][Times New Roman]] No
state or local agency?
[[167,2004,247,2052][10][,I,][Times New Roman]]iv. [[218,2004,562,2052][10][,,][Times New Roman]]For each identified [[708,2004,1001,2052][10][,,][Times New Roman]]wetland and wa [[970,2004,1221,2052
][10][,,][Times New Roman]]terbody on th [[1193,2004,1243,2052][10][,,][Times New Roman]]e [[1221,2004,1531,2052][10][,,][Times New Roman]]project site, prov [[1503,2004,1585,2052][10][,,][Times
New Roman]]ide [[1564,2004,1646,2052][10][,,][Times New Roman]]the [[1625,2004,2024,2052][10][,,][Times New Roman]]following information
Streams:Name ____________________________________________Classification _______________________
ûû úè
Lakesor Ponds:Name ____________________________________________Classification_______________________
Wetlands:Name ____________________________________________Approximate Size ___________________
ö×Ø×ÊÛÐ Å×ÈÐÛÎØÉ
Wetland No. (if regulatedbyDEC) _____________________________
õö
[[156,2257,225,2305][10][,I,][Times New Roman]]v. [[206,2257,1075,2305][10][,,][Times New Roman]]Are any of the above water bodies listed in the mo [[1046,2257,1954,2305][10][,,][Times
New Roman]]st recent compilation of NYS water quality-impaired [[2149,2257,2275,2305][10][,,][Times New Roman]] Yes [[2263,2257,2374,2305][10][,,][Times New Roman]] No
waterbodies?
If yes, name of impaired water body/bodies and basis for listing as impaired: _____________________________________________
___________________________________________________________________________________________________________
i.Is theproject site inadesignatedFloodway? Yes No
j.Is theproject site in the100year Floodplain? Yes No
k.Is theproject site in the500year Floodplain?
Yes No
l.Is the project site located over, or immediately adjoining, a primary, principal or sole source aquifer? Yes No
If Yes:
[[188,2806,250,2854][10][,I,][Times New Roman]]i. [[220,2806,2409,2854][10][,,][Times New Roman]]Name of aquifer: ____________________________________________________________________________________
_____
ìÊÓÎÙÓÌÛÐ ÛËÇÓÖ×Ê
Page 11 of 13
m.Identify the predominant wildlife species that occupy or use the project site: ______________________________
______________________________ _____________________________________________________________
ÅÔÓÈ× ÈÛÓÐ×Ø Ø××Ê
ÉÍÎÕ ÚÓÊØÉ
ÊÍØ×ÎÈÉ
______________________________ _____________________________________________________________
ÆÛÊÓÍÇÉ ÖÓÉÔ ÉÌ×ÙÓ×É
n.Does the project site contain a designated significant natural community? Yes No
If Yes:
[[188,371,250,419][10][,I,][Times New Roman]]i. [[220,371,353,419][10][,,][Times New Roman]]Descr [[317,371,418,419][10][,,][Times New Roman]]ibe [[379,371,2417,419][10][,,][Times New
Roman]]the habitat/community (composition, function, and basis for designation): _____________________________________
________________________________________________________________________________________________________
é×ØÕ× ï×ÛØÍÅ ï×ØÓÇÏ ö×Î ê×ØïÛÌÐ× èÛÏÛÊÛÙÑ ì×ÛÈ éÅÛÏÌ
[[177,467,250,515][10][,I,][Times New Roman]]ii. [[221,467,2412,515][10][,,][Times New Roman]]Source(s) of description or evaluation: ________________________________________________________________
________
îãéø÷ùÉ ÷ÎÆÓÊÍÎÏ×ÎÈÛÐ ê×ÉÍÇÊÙ× ïÛÌÌ×Ê
[[167,515,252,563][10][,I,][Times New Roman]]iii. [[222,515,297,563][10][,,][Times New Roman]]Ex [[269,515,751,563][10][,,][Times New Roman]]tent of community/habitat:
Currently: ______________________ acres
ÛÎØ
Following completion of project as proposed: _____________________ acres
ÛÎØ
Gain or loss (indicate + or -): ______________________ acres
îÍ ÙÔÛÎÕ×
o.Does project site contain any species of plant or animal that is listed by the federal government or NYS as Yes No
endangered or threatened, or does it contain any areas identified as habitat for an endangered or threatened species?
óìÛù ÓØ×ÎÈÓÖÓ×Ø ö×Ø×ÊÛÐ ÉÌ×ÙÓ×É ÌÍÈ×ÎÈÓÛÐ ÔÛÚÓÈÛÈ ×ÎØÛÎÕ×Ê×Ø óÎØÓÛÎÛ ÚÛÈ ïÃÍÈÓÉ ÉÍØÛÐÓÉ ÈÔÊ×ÛÈ×Î×Ø ÎÍÊÈÔ×ÊÎ ÐÍÎÕ×ÛÊ×Ø ÚÛÈ ÏÃÍÈÓÉ É×ÌÈ×ÎÈÊÓÍÎÛÐÓÉ
ÛÎØ ×ÎØÛÎÕ×Ê×Ø ñÛÊÎ×Ê ÚÐÇ× ÚÇÈÈ×ÊÖÐà ðÃÙÛ×ÓØ×É Ï×ÐÓÉÉÛ ÉÛÏÇ×ÐÓÉ
p.Does the project site contain any species of plant or animal that is listed by NYS as rare, or as a species of Yes No
special concern?
ìÛÐ× Ì×ÛÈ ÏÍÉÉ éÌÔÛÕÎÇÏ ÉÇÚÖÇÐÆÇÏ ÊÛÊ× ÙÊÓÈÓÙÛÐÐà ÓÏÌ×ÊÓÐ×Ø ÛÎØ ÉÙÍÊÌÓÍÎ Ö×ÛÈÔ×Ê ÏÍÉÉ éÙÍÊÌÓØÓÇÏ ÉÙÍÊÌÓÍÓØÓ×É ÊÛÊ× ÓÏÌ×ÊÓÐ×Ø
q.Is the project site or adjoining area currently used for hunting, trapping, fishing or shell fishing? Yes No
If yes, give a brief description of how the proposed action may affect that use: ___________________________________________
________________________________________________________________________________________________________
E.3. Designated Public Resources On or Near Project Site
a.Is the project site, or any portion of it, located in a designated agricultural district certified pursuant to Yes No
Agriculture and Markets Law, Article 25-AA, Section 303 and 304?
If Yes, provide county plus district name/number: _________________________________________________________________
b.Are agricultural lands consisting of highly productive soils present? Yes No
[[198,1924,260,1972][10][,I,][Times New Roman]]i. [[231,1924,2405,1972][10][,,][Times New Roman]]If Yes: acreage(s) on project site? _________________________________________________________________
__________
[[188,1972,261,2020][10][,I,][Times New Roman]]ii. [[232,1972,2408,2020][10][,,][Times New Roman]]Source(s) of soil rating(s): _______________________________________________________________________
__________
c.Does the project site contain all or part of, or is it substantially contiguous to, a registered National Yes No
Natural Landmark?
If Yes:
[[188,2192,250,2240][10][,I,][Times New Roman]]i. [[231,2192,911,2240][10][,,][Times New Roman]]Nature of the natural landmark: [[898,2192,1478,2240][10][,,][Times New Roman]] Biological
Community [[1476,2192,1847,2240][10][,,][Times New Roman]] Geological Feature
[[188,2240,261,2288][10][,I,][Times New Roman]]ii. [[232,2240,2405,2288][10][,,][Times New Roman]]Provide brief description of landmark, including values behind designation and approximate
size/extent: ___________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
d.Is the project site located in or does it adjoin a state listed Critical Environmental Area? Yes No
If Yes:
[[198,2519,260,2567][10][,I,][Times New Roman]]i. [[230,2519,2403,2567][10][,,][Times New Roman]]CEA name: ____________________________________________________________________________________________
_
õÐ×Î ðÛÑ×
[[188,2567,261,2615][10][,I,][Times New Roman]]ii. [[232,2567,2405,2615][10][,,][Times New Roman]]Basis for designation: ______________________________________________________________________________
_______
ú×Î×ÖÓÈ ÈÍ ÔÇÏÛÎ Ô×ÛÐÈÔ ÎÛÈÇÊÛÐ É×ÈÈÓÎÕ
[[177,2615,262,2663][10][,I,][Times New Roman]]iii. [[233,2615,2400,2663][10][,,][Times New Roman]]Designating agency and date: ______________________________________________________________________
________
èÍÅÎ ÍÖ ëÇ××ÎÉÚÇÊÃ
Page 12 of 13