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ne ee ee es von 14> Tdentity the typical hatvtat (ypes tint aceur on, or ure likely to be found on the project site, Check all that apply CUSboretine [] Forest [7] Agriculiualragstands ] Varly mid-suecessionl CwWetlaad CD Urban [eBsubarban "78. Pines ihe site of te propused action contain any species of wnimal, or associated Imbilats, listed by the State or Federal government as threatened or ettdangered? “ToC WS the project site Tooated in ihe 10-year flood plan? _ 17. WHHL the proposed action create storm water discharge, either from point or non-point sources? il ¥es, a, ‘Will storm water discharges flow to adjacent properties? fal CJ ! prostate | b. Will storm water discharges be directed to established conveyance systems (rmnoff and storm drains)? [a im ! LP Yes, briefly describe: i ' i t 1 j ! 18, Does the proposed action include construction or other activities that would result in the impoundment of water | NO | YES | j or other liquids (c.g., retention pond, waste lagoon, dam)? | | ; If Yes, explain the purpose and size of the impoundment: [ ‘a H 19, Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste | NO | YES management facility? i If Yes, deseribe: Oot CT 20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or | NO | YES completed) for hazardous waste? Hf Yes, describe: ras Cl ! [CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF | MY KNOWLEDGE - i af ’ t AppHennt/sponscyname: (\ ANSE. Uy Co \ ant ENG Date: a om [ en Co woven ed ; 1 Signature: ( ; pido We Co Oatna do Sr ‘Title: 3) 2/ aus | i t ! eee nee ere eet meer “PRINT FORM Pave Car?