Text · page 17 of 21
Read the whole document on one page (all 21 pages, each with its own heading)
This document was a scan. Its text was produced by character recognition and may contain errors; check the original for exact wording.
14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: [Shoreline [_] Forest [x] Agricultural/grasslands [_] Early mid-successional [-]Wetland [_] Urban Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or tT) va ]isWN O Federal government as threatened or endangered? Ela &]* [ BIBINE4 16. Is the project site located in the 100-year flood plan? ES < [| 17. Will the proposed action create storm water discharge, either from point or non-point sources? ES re If Yes, PLL a. Will storm water discharges flow to adjacent properties? | b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? If Yes, briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water N YES OC} or other liquids (e.g., retention pond, waste lagoon, dam)? If Yes, explain the purpose and size of the impoundment: PIL 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? — 7 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: I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: Dam van Coc Ver Date: “| s\ Le Signature: BES Title ow noe | a ee ™. PRINT FORM Page 3