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14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: ClShoreline [_] Forest [x] Agricultural/grasslands [_] Early mid-successional (wetland [J Urban Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or NO | YES Federal government as threatened or endangered? L 16, Is the project site located in the 100-year flood plan? NO | YES L] 17. Will the proposed action create storm water discharge, either from point or non-point sources? NO _| YES If Yes, a. Will storm water discharges flow to adjacent properties? b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? Tf Yes, briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water | NO or other liquids (e.g., retention pond, waste lagoon, dam)? Tf Yes, explain the purpose and size of the impoundment: 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste NO 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 completed) for hazardous waste? If Yes, describe: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsorname; _Daraiwr — @acver Date: 41 S\L& Signature: Ca Title: Oy 2A” i — = PRINT FORM Page 3 of 3