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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: [Shoreline [_] Forest [_] Agricultural/grasslands [_] Early mid-successional C]Wetland [[) Urban Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or O Zz Federal government as threatened or endangered? a Sls 16. 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? o) Z If Yes, RII 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 NO | YES or other liquids (e.g., retention pond, waste lagoon, dam)? If Yes, explain the purpose and size of the impoundment: Gi a 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? 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: 7 I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/nam Gm Y bed A ( Date: \ Zo | 25 seme \rnrQele I Title: Ar’) PRINT FORM Page 3 of 3