Long EAF Full Environmental Assessment Form
Part I -Project and Setting
Instructions for Completing Part I
Part 1 is to be completed by the applicant or project sponsor. 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;indicate whether missing information does not exist,
or is not reasonably available to the sponsor;and,when possible,generally describe work or studies which would be necessary to
update or fully develop that information.
Applicants/sponsors must complete all items in Sections A&B. In Sections C,D&E,most items contain an initial question that
must be answered either"Yes"or"No". If the answer to the initial question is"Yes",complete the sub-questions that follow. If the
answer to the initial question is"No",proceed to the next question. Section F allows the project sponsor to identify and attach any
additional information. Section G requires the name and signature of the applicant or project sponsor to verify that the information
contained in Part lis accurate and complete.
A.Project and Applicant/Sponsor Information.
Name of Action or Project:
NEIGHBORHOOD RESIDENTIAL-DAY-CARE ZONING AMENDMENT
Project Location(describe,and attach a general location map):
TOWN-WIDE IN THE NR ZONING DISTRICT
Brief Description of Proposed Action(include purpose or need):
THE PROPOSAL IS TO ADD'DAY-CARE'AS AN ALLOWED USE BY SITE PLAN REVIEW IN THE NR ZONE IN THE TOWN OF QUEENSBURY
Name of Applicant/Sponsor: Telephone:
Queensbury Masonic Historical Society E-Mail:
Address:15 Burke Drive
City/PO:Queensbury State:NY Zip Code:12804
Project Contact(if not same as sponsor;give name and title/role): Telephone:518-668-2199
Matthew F Fuller,Esq./Meyer Fuller&Stockwell,PLLC E-Mail:
mfuller@meyerFuller.com
Address:
1557 State Route 9
City/PO: State: F128
p Code:
Lake George New York 45
Property Owner (if not same as sponsor): Telephone:
E-Mail:
Address:
City/PO: State: Zip Code:
Page 1 of 13
FEAF 2019
B.Government Approvals
B.Government Approvals,Funding,or Sponsorship. ("Funding"includes grants,loans,tax relief,and any other forms of financial
assistance.)
Government Entity If Yes:Identify Agency and Approval(s) Application Date
Required (Actual or projected)
a.City Counsel,Town Board, ®YesONo Town Board,Town of Queensbury
or Village Board of Trustees
b.City,Town or Village QYesMNo
Planning Board or Commission
c.City,Town or QYes[--]No
Village Zoning Board of Appeals
d.Other local agencies []YesE]No
e.County agencies OYesE]No Warren County Planning
f.Regional agencies E]YesONo
g.State agencies E]YesONo
h.Federal agencies QYesMNo
i. Coastal Resources.
i. Is the project site within a Coastal Area,or the waterfront area of a Designated Inland Waterway? ❑YeS®NO
ii. Is the project site located in a community with an approved Local Waterfront Revitalization Program? ❑Yes®No
X. Is the project site within a Coastal Erosion Hazard Area? ❑Yes[Z]No
C.Planning and Zoning
C.I.Planning and zoning actions.
Will administrative or legislative adoption,or amendment of a plan,local law,ordinance,rule or regulation be the ®YesONo
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 ®YesE3No
where the proposed action would be located?
If Yes,does the comprehensive plan include specific recommendations for the site where the proposed action OYes®No
would be located?
b.Is the site of the proposed action within any local or regional 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, E]YesmNo
or an adopted municipal farmland protection plan?
If Yes,identify the plan(s):
Page 2 of 13
C.3. Zoning
a. Is the site of the proposed action located in a municipality with an adopted zoning law or ordinance. ®YesONo
If Yes,what is the zoning classification(s)including any applicable overlay district?
NEIGHBORHOOD RESIDENTIAL-NR
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? ®YesONo
If Yes,
i. What is the proposed new zoning for the site?NR BUT ALLOW DAY-CARE IN THE NR ZONE
CA.Existing community services.
a.In what school district is the project site located?OUEENSBURY
b.What police or other public protection forces serve the project site?
WARREN COUNTY SHERIFF NYS TROOPERS
c.Which fire protection and emergency medical services serve the project site?
LOCAL EMS AND FIRE
d.What parks serve the project site?
NA
D.Project Details
D.I.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)?COMMERCIAL, RESIDENTIAL
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
i. If Yes,what is the approximate percentage of the proposed expansion and identify the units(e.g.,acres,miles,housing units,
square feet)? % Units:
d.Is the proposed action a subdivision,or does it include a subdivision? DYes ONo
If Yes,
i. Purpose or type of subdivision?(e.g.,residential,industrial,commercial;if mixed,specify types)
ii. Is a cluster/conservation layout proposed? DYes ONNo
iii. Number of lots proposed?
iv.Minimum and maximum proposed lot sizes? Minimum Maximum
e.Will the proposed action be constructed in multiple phases? ❑YesElNo
i. If No,anticipated period of construction: months
ii. If Yes:
• Total number of phases anticipated
• Anticipated commencement date of phase 1 (including demolition) month year
• Anticipated completion date of final phase month wear
• Generally describe connections or relationships among phases,including any contingencies where progress of one phase may
determine timing or duration of future phases:
Page 3 of 13
f.Does the project include new residential uses? ❑Yes[]No
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)? ❑YesnNo
If Yes,
f.Total number of structures
ii.Dimensions(in feet)of largest proposed structure: height; width; and length
iii. Approximate extent of building space to be heated or cooled: 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,
f. Purpose of the impoundment:
ii. If a water impoundment,the principal source of the water: ❑Ground water❑Surface water streams[]Other specify:
iii. If other than water,identify the type of impounded/contained liquids and their source.
iv. Approximate size of the proposed impoundment. Volume: million gallons;surface area: acres
v. Dimensions of the proposed dam or impounding structure: height; length
vi. Construction method/materials for the proposed dam or impounding structure(e.g.,earth fill,rock,wood,concrete):
D.2. Project Operations
a.Does the proposed action include any excavation,mining,or dredging,during construction,operations,or both? ❑YesE]No
(Not including general site preparation,grading or installation of utilities or foundations where all excavated
materials will remain onsite)
If Yes:
i.What is the purpose of the excavation or dredging?
ii. How much material(including rock,earth,sediments,etc.)is proposed to be removed from the site?
• Volume(specify tons or cubic yards):
• Over what duration of time?
iff. Describe nature and characteristics of materials to be excavated or dredged,and plans to use,manage or dispose of them.
iv. Will there be onsite dewatering or processing of excavated materials? ❑YesONo
If yes,describe.
v. What is the total area to be dredged or excavated? acres
vi. What is the maximum area to be worked at any one time? acres
vii. What would be the maximum depth of excavation or dredging? feet
viii. Will the excavation require blasting? []XesONo
ix. 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 []YesONo
into any existing wetland,waterbody,shoreline,beach or adjacent area?
If Yes:
f. Identify the wetland or waterbody which would be affected(by name,water index number,wetland map number or geographic
description):
Page 4 of 13
H. Describe how the proposed action would affect that waterbody or wetland,e.g.excavation,fill,placement of structures,or
alteration of channels,banks and shorelines. Indicate extent of activities,alterations and additions in square feet or acres:
iii.Will the proposed action cause or result in disturbance to bottom sediments? ❑YesONo
If Yes,describe:
iv. Will the proposed action cause or result in the destruction or removal of aquatic vegetation? ❑YesE]No
If Yes:
• acres of aquatic vegetation proposed to be removed:
• expected acreage of 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):
v. Describe any proposed reclamation/mitigation following disturbance:
c.Will the proposed action use,or create a new demand for water? []Yes E]No
If Yes:
i. Total anticipated water usage/demand per day: gallons/day
ii. Will the proposed action obtain water from an existing public water supply? []Yes Flo
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? ❑Yesn No
• Is expansion of the district needed? ❑Yes[]No
• Do existing lines serve the project site? ❑Yes[]No
iff. Will line extension within an existing district be necessary to supply the project? ❑Yes E]No
If Yes:
• Describe extensions or capacity expansions proposed to serve this project:
• Source(s)of supply for the district:
iv. Is a new water supply district or service area proposed to be formed to serve the project site? ❑Yes❑No
If,Yes:
• Applicant/sponsor for new district:
• Date application submitted or anticipated:
• Proposed source(s)of supply for new district:
v. If a public water supply will not be used,describe plans to provide water supply for the project:
vi.If water supply will be from wells(public or private),what is the maximum pumping capacity: gallons/minute.
d.Will the proposed action generate liquid wastes? ❑Yes E]No
If Yes:
i. Total anticipated liquid waste generation per day: gallons/day
H.Nature of liquid wastes to be generated(e.g.,sanitary wastewater,industrial;if combination,describe all components and
approximate volumes or proportions of each):
X. Will the proposed action use any existing public wastewater treatment facilities? ❑Yes❑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 E]No
• Is expansion of the district needed? ❑YesONo
Page 5 of 13
• Do existing sewer lines serve the project site? ❑Yes❑No
• Will a line extension within an existing district be necessary to serve the project? ❑Yes❑No
If Yes:
• Describe extensions or capacity expansions proposed to serve this project:
iv. Will a new wastewater(sewage)treatment district be formed to serve the project site? ❑Yes❑No
If Yes:
• Applicant/sponsor for new district:
• Date application submitted or anticipated:
• What is the receiving water for the wastewater discharge?
v. If public facilities will not be used,describe plans to provide wastewater treatment for the project,including specifying proposed
receiving water(name and classification if surface discharge or describe subsurface disposal plans):
vi. 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:
i. How much impervious surface will the project create in relation to total size of project parcel?
Square feet or acres(impervious surface)
Square feet or acres(parcel size)
ii. Describe types of new point sources.
iii. Where will the stormwater runoff be directed(i.e.on-site 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
iv. Does the proposed plan minimize impervious surfaces,use pervious materials or collect and re-use stormwater? ❑Yes❑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:
i.Mobile sources during project operations(e.g.,heavy equipment,fleet or delivery vehicles)
u. Stationary sources during construction(e.g.,power generation,structural heating,batch plant,crushers)
iii. 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:
i. Is the project site located in an Air quality non-attainment area? (Area routinely or periodically fails to meet ❑Yes❑No
ambient air quality standards for all or some parts of the year)
ii. In addition to emissions as calculated in the application,the project will generate:
• Tons/year(short tons)of Carbon Dioxide(CO2)
• Tons/year(short tons)of Nitrous Oxide(N20)
• Tons/year(short tons)of Perfluorocarbons(PFCs)
• Tons/year(short tons)of Sulfur Hexafluoride(SF6)
• Tons/year(short tons)of Carbon Dioxide equivalent of Hydroflourocarbons(HFCs)
• Tons/year(short tons)of Hazardous 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[1No
landfills,composting facilities)?
If Yes:
i.Estimate methane generation in tons/year(metric):
ii.Describe any methane capture,control or elimination measures included in project design(e.g.,combustion to generate heat or
electricity,flaring):
i.Will the proposed action result in the release of air pollutants from open-air operations or processes,such as DYesE]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 []YesE]No
new demand for transportation facilities or services?
If Yes:
i. When is the peak traffic expected(Check all that apply): []Morning ❑Evening []Weekend
❑Randomly between hours of to
ii. For commercial activities only,projected number of truck trips/day and type(e.g.,semi trailers and dump trucks):
iii. Parking spaces: Existing Proposed Net increase/decrease
iv.Does the proposed action include any shared use parking? E]Yes❑No
v If the proposed action includes any modification of existing roads,creation of new roads or change in existing access,describe:
vi. Are public/private transportation service(s)or facilities available within'/2 mile of the proposed site? DYesFINo
vii Will the proposed action include access to public transportation or accommodations for use of hybrid,electric DYesONo
or other alternative fueled vehicles?
viii.Will the proposed action include plans for pedestrian or bicycle accommodations for connections to existing DYesnNo
pedestrian or bicycle routes?
k.Will the proposed action(for commercial or industrial projects only)generate new or additional demand []YesONo
for energy?
If Yes:
i. Estimate annual electricity demand during operation of the proposed action:
U. Anticipated sources/suppliers of electricity for the project(e.g.,on-site combustion,on-site renewable,via grid/local utility,or
other):
iii. Will the proposed action require a new,or an upgrade,to an existing substation? (]YesFlNo
1.Hours of operation. Answer all items which apply.
i. During Construction: ii. During Operations:
• Monday-Friday: a Monday-Friday:
• Saturday: • Saturday:
• Sunday: • Sunday:
• Holidays: • Holidays:
Page 7 of 13
in.Will the proposed action produce noise that will exceed existing ambient noise levels during construction, ❑Yes❑No
operation,or both?
If yes:
i. Provide details including sources,time of day and duration:
ii. Will the proposed action remove existing natural barriers that could act as a noise barrier or screen? ❑Yes❑No
Describe:
n.Will the proposed action have outdoor lighting? ❑Yes❑No
If yes:
i. Describe source(s),location(s),height of fixture(s),direction/aim,and proximity to nearest occupied structures:
H. Will proposed action remove existing natural barriers that could act as a light barrier or screen? ❑Yes[]No
Describe:
o.Does the proposed action have the potential to produce odors for more than one hour per day? ❑Yes❑No
If Yes,describe possible sources,potential frequency and duration of odor emissions,and proximity to nearest
occupied structures:
p.Will the proposed action include any bulk storage of petroleum(combined capacity of over 1,100 gallons) ❑Yes❑No
or chemical products 185 gallons in above ground storage or any amount in underground storage?
If Yes:
i. Product(s)to be stored
ii. Volume(s) per unit time (e.g.,month,year)
iii. Generally,describe the proposed storage facilities:
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:
i. Describe proposed treatment(s):
ii. Will the proposed action use Inte rated Pest Management Practices? ❑ Yes ❑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:
i. Describe any solid waste(s)to be generated during construction or operation of the facility:
• Construction: tons per (unit of time)
• Operation : tons per (unit of time)
ii.Describe any proposals for on-site minimization,recycling or reuse of materials to avoid disposal as solid waste:
• Construction:
• Operation:
iii. Proposed disposal methods/facilities for 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:
i. Type of management or handling of waste proposed for the site(e.g.,recycling or transfer station,composting,landfill,or
other disposal activities):
ii. Anticipated rate of disposal/processing:
• Tons/month,if transfer or other non-combustion/thermal treatment,or
• Tons/hour,if combustion or thermal treatment
iii. If landfill,anticipated site life: years
t.Will the proposed action at the site involve the commercial generation,treatment,storage,or disposal of hazardous❑Yes❑No
waste?
If Yes:
i.Name(s)of all hazardous wastes or constituents to be generated,handled or managed at facility:
H. Generally describe processes or activities involving hazardous wastes or constituents:
iii.Specify amount to be handled or generated tons/month
iv. Describe any proposals for on-site minimization,recycling or reuse of hazardous constituents:
v. Will any hazardous wastes be disposed at an existing offsite hazardous waste facility? ❑Yes❑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.I.Land uses on and surrounding the project site
a.Existing land uses.
i. 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):
H. 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
i. If Yes:explain:
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,
i. Identify Facilities:
QUEENSBURY SCHOOL
e.Does the project site contain an existing dam? ❑Yes❑No
If Yes:
i. Dimensions of the dam and impoundment:
• Dam height: feet
• Dam length: feet
• Surface area: acres
• Volume impounded: gallons OR acre-feet
ii. Dam's existing hazard classification:
W. 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:
i. Has the facility been formally closed? ❑Yes❑No
• If yes,cite sources/documentation:
ii. Describe the location of the project site relative to the boundaries of the solid waste management facility:
W. 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:
i. 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:
L Is any portion of the site listed on the NYSDEC Spills Incidents database or Environmental Site ❑Yes❑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
ii. If site has been subject of RCRA corrective activities,describe control measures:
W. Is the project within 2000 feet of any site in the NYSDEC Environmental Site Remediation database? ❑Yes❑No
If yes,provide DEC ID number(s):
iv. If yes to(i),(ii)or(iii)above,describe current status of site(s):
Page 10 of 13
v. Is the project site subject to an institutional control limiting property uses? ❑Yes❑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? NA 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: %
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: %of site
❑ Moderately Well Drained: %of site
❑ Poorly Drained %of site
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.
i.Does any portion of the project site contain wetlands or other waterbodies(including streams,rivers, ❑Yes❑No
ponds or lakes)?
ii.Do any wetlands or other waterbodies adjoin the project site? ❑Yes❑No
If Yes to either i or ii,continue. If No,skip to E.2.i.
iii. Are any of the wetlands or waterbodies within or adjoining the project site regulated by any federal, Oyes❑No
state or local agency?
iv. For each identified regulated wetland and waterbody on the project site,provide the following information:
• Streams: Name Classification
• Lakes or Ponds: Name Classification
• Wetlands: Name Approximate Size
• Wetland No.(if regulated by DEC)
v. Are any of the above water bodies listed in the most recent compilation of NYS water quality-impaired ❑Yes❑No
waterbodies?
If yes,name of impaired water bodylbodies and basis for listing as impaired:
i.Is the project site in a designated Floodway? ❑Yes❑No
j.Is the project site in the 100-year Floodplain? ❑Yes❑No
k.Is the project site in the 500-year Floodplain? ❑Yes❑No
1.Is the project site located over,or immediately adjoining,a primary,principal or sole source aquifer? ❑Yes❑No
If Yes:
i.Name of aquifer:
Page 11 of 13
in. Identify the predominant wildlife species that occupy or use the project site:
n.Does the project site contain a designated significant natural community? ❑Yes❑No
If Yes:
i. Describe the habitat/community(composition,function,and basis for designation):
if. Source(s)of description or evaluation:
W. Extent of community/habitat:
• Currently: acres
• Following completion of project as proposed: acres
• Gain or loss(indicate+or-): acres
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?
If Yes:
i. Species and listing(endangered or threatened):
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?
If Yes:
i. Species and listing:
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
i. If Yes:acreage(s)on project site?
ii. 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:
i. Nature of the natural landmark: ❑Biological Community ❑ Geological Feature
ii.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:
i. CEA name:
H.Basis for designation:
iii. Designating agency and date:
Page 12 of 13
[e.Does the project site contain,or is it substantially contiguous to,a building,archaeological site,or district ❑YesONo
which is listed on the National or State Register of Historic Places,or that has been determined by the Commissioner of the NYS
Office of Parks,Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places?
f Yes:
i. Nature of historic/archaeological resource: ❑Archaeological Site ❑Historic Building or District
ii.Name:
iii.Brief description of attributes on which listing is based:
f.Is the project site,or any portion of it,located in or adjacent to an area designated as sensitive for ❑Yes®No
archaeological sites on the NY State Historic Preservation Office(SHPO)archaeological site inventory?
g.Have additional archaeological or historic site(s)or resources been identified on the project site? ❑Yes®No
If Yes:
i.Describe possible resource(s):
ii.Basis for identification:
h.Is the project site within fives miles of any officially designated and publicly accessible federal,state,or local ❑Yes QNo
scenic or aesthetic resource?
If Yes:
i.Identify resource:
ii.Nature of,or basis for,designation(e.g.,established highway overlook,state or local park,state historic trail or scenic byway,
etc.):
W.Distance between project and resource: miles.
i. Is the project site located within a designated river corridor under the Wild,Scenic and Recreational Rivers ❑Yes®No
Program 6 NYCRR 666?
If Yes:
i.Identify the name of the river and its designation:
U.Is the activity consistent with development restrictions contained in 6NYCRR Part 666? []Yes oNo
F.Additional Information
Attach any additional information which may be needed to clarify your project.
If you have identified any adverse impacts which could be associated with your proposal,please describe those impacts plus any
measures which you propose to avoid or minimize them.
G. Verification
I certify that the information provi ed is true to the best of my owledge.
Applicant/Sponsor Name � el- Date
Signature Title
c
PRINT FORM Page 13 of 13