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| td. Identify the typical habitat types that accut on, or are likely to be found on the project site, Check all that apply: (“TShoreline [7] Forest C7 Aericultural/erasslands [7] Harly mid-successional CJ Wetlant [0] Uroan (7 Suburban 15, Does the site of the proposed action contain any species of animal, or assoclated habitats, listed by the State or Federal government as threatened or endangered? ES Zz Oo me i C1 KI Li 16, Is the project alte located jn the [00-year flood plan? ne ow ty =| (7, Will the proposed action create storm water dischar ge, elther from point or non-point sources? Lo 9) leyy If Yes, a Px] LTibs a. Will storm water discharges flow to adjacent properties? CNS b. Will storm water discharges be directed to i conveyalice systems (runoff and storm drains)? PY brefly desoribe ocinWater wil on to abjalek storm Ara rns. [8. Does the proposed action Include construction or ather activities that would result in the impoundment or other liquids (6.2., retention pond, waste lagoon, dam)? of water NO |} YES If Yes, explain the purpose and size of the im poundment: ix a 2. Hag the site of the proposed actlon or an adjoining propert y been the location of an active or Closed solid waste | NO management facility? [ YES en If Yes, describe; — MO 20,Has the site of the proposed action or an adjoining propert y been the subject of remediation (ongolng or NO | YES completed) for hazardous waste? (? Yes, desoribe; YCERTIFY TAAT THE INFORMATION PROVI DED ABOVE IS TRUE AND ACCURATE TO THE MY KNOWLEDGE BEST OF Appticant/ jel ADL vas. 4/4 [201g Signature: _Title: LY titi. Dit ECiOr PRINT FORM Page 3 of 3