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l4. Identify the typtoal habitat types that occur
on, or are likely to be found on the project site, Check
all that apply:
[“JShoreline [7] Forest [] Agricultural/grasstands [J Early mid-suecessional
FUWwettand = [C} Urban {71 Suburban
(3, Does the siteof the proposed action contain any
specie s of animal, or assoclated habitats, Hsted by the State
Federal government as threatened or endangered
?
or
iE TR
im
iopecle! ollie
16. fs the project tte located in the 100-yoar
flood plan?
YE
a %
17, Will the proposed action create storm water discha
If Yas,
rge, elther from point or non-point sources?
;
Wa)
as
ui
esl Tbe
a, Will storm water discharges flow to adjacent
properties?
b, Will storm water d ischarges be directed to es
If Yes, briefly describe: er ey -_, |
conveyance systems (runoff and storm drains)?
ov to 4 hic Lek sty Ay
~~
SQ ms.
18. Does the proposed action Include construction
or other activities that would result in the impoundment of water
or other liquids (e.¢., retention pond, waste lagoon [NO | YES
If Yes, explain the purpose and size of the impou , damn)?
ndment:
19, Haa the site of the proposed action or an
adjoining property been the location of an active
management facility? or clased solid waste NO | YES
If Yes, desorlba:
————
ANE]
20.Has the sits of the proposed action or an adjoinin
completed) for hazardous waste? g property been the subject of remediation (ongoing or
NO | YES
™(f Yes, describe:
~ |
pthread
1 CERTIFY THAT THE INFORMATION
PROVIDED ABOVE IS TRUE AND ACCU
MY KNOWLEDGE RATE TO THE BEST OF
Applicanté
esi LID vue 4/4 [oe
Signature:
_Title: Ex eeu Director
| PRINT FORM
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