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ria Tdentlly the typical habitat types that oecur of, dr dre [ely Ww be found ou the project
site. Check all that apply:
(JShorelite [Z] Forest [] Ageeultaval/gewslands [7] Bory mid-suceesetonal
Chwedend {C) urban Plsububan
TS. Does the site of tie proposed action contain any syetier GF antiial, of assodinted habitats, listed by the Stated or | Ney YRS
Pederal government us threatened or endangored? j Cj
16. Isthe project site located in the 100-year flood plant N Was
17, Will the propose action
ne create stor water discharge, &elihot from point or non-point sources?
__ {3
tf Yes, :
I
a. Will storm water discharges flow to adjacent properties?
Id
b. Will storm water discharges be ditected to established conveyance systems (runoff and. storm drains)?
If Yes, briedly desariba:
io
18 Does ihe proposed action include constraction or other activities that would result in the impoundment of water NO 1 YES
or other liquids (6.g., retention pond, waste lagoon, darn)?
If Yes, explain the purpose and size of the impoundment:
19. Has the site of the pr posed action or.an adjoining property ‘been the! location ofan i petive or closed solid waste NO_ YES
management facility? : i
If ¥os, deseribo:
20.Aas the site of the proposed action or an adjoining pe operty beet the subject of remediation (ongoing or : WO} ¥RS i
completed) for hazardous waste? . : ~ -
If Yes, desoriber .
a.0]
' CERTIFY THAT THE INFORMATION PROVIDED ABOVE 15 TRUE AND ACCURATE TO THE BEST OF
MY KNOWLEDGE
Applicant/sponsor/name: Co CL, Co ich END Date: 4 a./ alo
Signature: ( Beste ColetraraS Titles, 3 3. Alen
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