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Short Environmental Assessment Form
Part I - Project Information
Tusiructions for Completing
Part { — Project Information, The x vplicant or project sponsor is responsthle
application for approval or finding, are subject to public for the com pletion of Part l, Responses become
part of the
information currently available, If additional rosear
review,
and may be subject to further verification, Complete Part
oh or investigation would be needed to fully respon 1 based on
thoroughly as possible based on current information, d to any tiem, please answer as
'
Complete all items in Part 1, You may also provid
e any additional information which you believe
lead agency; attach additional Pages a3 necess will be needed by or useful to the
ary to supplement any item.
Part I ~ Project and Sponsor in formation
Name of Action or Project: M p / E- | Ny A/ y
Project Location (desori 6, and Sy. a
location map):
144 er
Brlef Desoription of Proposed Actlon:
Name of Applicant or Sponsor:
| it "A Telephon
Lakawe Io hous; hy Nek 0) pve 4 . oO
of pr" lof
ti
,
E-Mail: 4c AGIZe, pew
« 7s Pa
Address: hi f “4 |
SE@ hA corp will yon
“ vy
City/PO: I es
Lackawatte WY
State: Zip Code:
{, Does the propos ed action only involve the legislative adoption
adiministative rule, or regulation? ofa plan, focal law, ordinance, 2re NO YES
If Yes, attach a natrative description of the intent of the ;
proposed action and the enylronmental resources that ———
nay be affected tn the municipality and proceed to 4 [J
Part 2, If fo, continue to question 2,
2. Does the proposed action require a permit, approv |
al or funding from any other government Agenc
Mew Work State. fe mes iy
if Yes, list ageney(s) name an porinit or approv y? NO YES
3. a, Total acreage of the site of the propos community Feey
al: . |
ed action?
5. Total acreage to be physically disturbed? wd acres
Ll | x
¢, Tofal acreage (project site and any contig _ at acres
uous properties) owned
or controlled by the applicant or project sponsor?
wf acres
4, Cheok all land uses that occur on, are adjoin
ing or near the proposed action:
[[] Uroan 7] Raval (non-agriculiurey [J Industrial ["] Commercial A residential (suburban)
[_] Forest CJ Agriculture [] Aquatic [CT] Other(Specify):
[] Parkland
Pages | ol3
. SEAF 2019