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U4) identify the typical habitat types that occur on, -are likely to be foundon the project site. Check all that apply CUShoreline [5] Forest [7] Agricultural grasslands (7) Carly mid-suceessional CiwWetland [7 Urban (Ssuburban = 18. Does the site of the propased action contain any species of animal, or associated habitats,s. fisted bvy the Si ator | NO | YES Federal government as threatened or endangered? 46. Is the project site located in the 100-year flood plan? 17. Will the proposed action create storm water discharge, either from point or non-point sources? if Ves, a. Will storm water discharges flow to adjacent properties? b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? ifVes, briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water or other liquids (¢.g., retention pond, waste lagoon, dam)? if 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 management facility? if Yes, describe: 20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or completed) for hazardous waste? If Yes, describe: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE [8 TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: (ask - “0 Jc CN G Date: 4] om [ Or Lo Sigmature: we 3/2.) BU RINT FORM | Pave Sot