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V4) Identity the wpical habitat types that oceur on, or are likely to be found on the project site. ( “feck all that apply. ; [Shoreline [2] Forest a) Agricultural grasslands [7] Farly mid-suecessional Clwetland (0 Urban [Bsuburban _ 1S. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the Stateor = NOU) YES | Federal government as threatened or endangered? oan 16. Is the project site located in the 100-year flood plan? 27. Willthe proposed action create storm water discharge, either from point or non-point sources? iif ¥ e8, 3. Wil storm water discharges flow to adjacent properties? b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? | lf ¥es, briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water | NO | YES | or other liquids (e.g., retention pond, waste lagoon, dam)? if Yes, explain the purpose and size of the impoundment: 49, 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? If Yes, describe: 20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or NO | YES completed) for hazardous waste? if Yes, describe: ICERTISY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: wie y Lo are ENO Date: 4 on ( Lo Signature: . ae ize ro kg & Title: 3/ 2. Qs PRINT FORM Pane Sot 3