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to be found on the project site. Check all that apply: 14, Identify the typical habitat types that occur on, oF are likely OShoreline O Forest ([] Agricultural/grasslands D Early mid-successional (wetland © Urban [) Suburban State or ES species of animal, or associated habitats, listed by the 15. Does the site of the proposed action contain any < Federal government as threatened or endangered? CaO O ES ~< r flood plain? 16. Is the project site located in the 100-year or 500-yea O NO iS3) 7.) ~< ge, either from point or non-point 17. Will the proposed action create storm water dischar sources?If Yes, oloo OOO a. Will storm water discharges flow to adjacent properties? conveyance systems (runoff and storm drains)? b. Will storm water discharges be directed to established Hf Yes, briefly describe: of water NO | YES other activities that would result in the impoundment 18. Does the proposed action include construction or dam)? or other liquids (e.g., retention pond, waste lagoon, oO of the impoun dment: If Yes, explain the purpose and size waste NO | YES property been the location of an active or closed solid 19. Has the site of the proposed action or an adjoining management facility? oO gO If Yes, describe: ation (ongoing or NO | YES property been the subject of remedi 20.Has the site of the proposed action or an adjoining completed) for hazardous waste? If Yes, describe: a disadvantaged community? 21. Is the project located within, or within % mile of, Oo antaged community? Oo If No, could impacts from the project affect a disadv ing question. If Yes to either question in 21, answer the follow either direct or indirect, that may occur within the a. Identify the potential pollution impacts of the project, ges, air emissions, noise, odors, solid or hazardous waste disadvantaged community (¢.g., wastewater dischar generation or management): OF ABOVE IS TRUE AND ACCURATE TO THE BEST 1 CERTIFY THAT THE INFORMATION PROVIDED MY KNOWLEDGE Date; 8/10/26 Applicant/sponsor/name:_Russ Belscher Title: Maver Signature: SEAF 2026 Page 3 of 3