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i4. Identify the typloal habitat types that occur
on, or are likely to be found on the project site, Check all
["JShoreline that apply:
[7] Forest ("] Ageloultural/grasstands [7] Early mid-suceessional
CJWetland :
(CT Urban [7 Suburban
(5, Does the site of the proposed action contai
n any species of animal, or associated habitats,
Federal government as threatened of endan listed by the State or |_NO
gered?
fa
a
16. Is the project site located fn the { 00-year I
U
flood plan?
NO YE
CR
Cj
ae
(7, Will the proposed action create storm
water discharge, alther from point or non-p NO
If Yes, oint sources?
YE
tA
ial wi
SS
a, Will storm water discharges Alow to adjac
im
ent prope rties?
b, Will storm water discharges ba directedt to established
If Yas, brlofly desorthe:
‘ | si
conveyance systems (runoff and storm drains)?
i”
a Werke | will How toa |ale a Sro
fe
cM
ais .
[8. Does the proposed action include const
ruction or other activities that would result
or other liquids (.¢., retention pond, waste in the impoundment of water | WO | YES
lagoon, dani)?
If Yes, oxplain the putpose and size of
the impoundment;
19, Has the site of the proposed action or an
adjoi ning property been the location of an active or
managemsnt facility? closed solid waste NO | YES
If Yes, deseribe:
AN
20.Eas the site of the proposed action of au
adjoining property been the subject of remediat
completed) for hazardaus waste? ion (ongoing or : NO | YES
If Yes, desoribe:
tie
[0,7]
1 CERTINY THAT THE INFORMATION
PROVIDED ABOVE IS TRUE AND ACCU
MY KNOWLEDGE RATE TO THE BEST OF
Applicant
. ei LAD t Date: a/4 [Pole
Signature:
Title: Ey euithive Direc Or
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