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project site. Check all that apply: occur on, or ate likely to be found on the 14. Identify the typical habitat types that Early mid-successional [_]Shoreline [_| Forest rT] Agricultural/grasslands [_] []Wetland [7] Urban |v] Suburban listed by the State or in any species of animal, or associated habitats, 15. Does the site of the proposed action conta joo OeiOle BINISIE ISIC gered? Federal government as threatened or endan ear flood plan? 16. Is the project site located in the 100-y YES oint sources? water discharge, either from point or non-p 17. Will the proposed action create storm If Yes, nt properties? a. Will storm water discharges flow to adjace storm drains)? ted to estab lished conveyance systems (runoff and b. Will storm water discharges be direc If Yes, briefly describe: in the impo undment of water NO | YES ruction or other activities that would result 18. Does the proposed action include const lagoon, dam)? or other liquids (e.g., retention pond, waste If Yes, explain the purpose and size of the impo undment: LI NO | YES or an adjoining property been the location of an active or closed solid waste 19. Has the site of the proposed action - management facility? If Yes, describe: Ca NO | YES an adjoining property been the subject of remediation (ongoing or 0.Has the site of the proposed action or oo completed) for hazardous waste? If Yes, describe: a ACCURATE TO THE BEST OF ON PROVIDED ABOVE 1S TRUE AND ICERTIFY THAT THE INFORMATI MY KNOWLEDGE Date: )S | Al | 2,024, ee ZZ Aljison Cullens, Carissa Ferrucci ’] Title: Owners CC a Signature: he Ce ee PRINT FORM Page 3 of 3