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[4. Identify the typical habitat types that occur
on, or are likely to be found on the project site. Check all
that apply:
CShoretine [7] Forest CJ Agticultural/grasslands {7 Early mld-successional
ET Wetland (CT Urban £74 Suburban
{5, Does the site of the proposed action contain any specie
s of animal, or associated habitats, listed by the State or
Federal government as threatened or endangered?
"16. Is tho project site located in the {00-y
ear flood plan?
iv
{7, Will the proposed action create storm water
[]
If Yes,
discharge, elther from point or non “point source
s? NO
]
a, Will storm water discharges flow to adjacent proper
ties?
b, Will ston water discharges ba directed to established
conveyance systems (runoél and storm drains)?
Iv]
If'Yes, briefly desortbo: ¢ | “rh ‘ | 7 | fe Ed
foc
WN Weyer wi | OW to gy fle | Sfor™
LALG rns.
18. Does the proposed action include construction
or other actlvities that would result in the impoundmen
| or other liquids (o.g., retention pond, waste lagoon, t of water |NO | YES
dam)?
lf Yes, explain the purpose and size of the im
poundinent:
Lx co
9, Has the site of the proposed action or an adjoining
proper ty been the locatlou of an active or closed solid waste
management facility? [NO [YRS
If Yes, describe:
Bi CO
20.{Jas the site ofthe proposed action or an adjoin
ing property been the subject of remediation (ongoing or
completed) for hazardous waste? NO | YES
If Yes, describe:
pat
[x
I CERTOFY THAT THE IN FORMATION PROV
IDED ABOVE 15 TRUE AND ACCURATE TO
MY KNOWLEDGE THE BEST OF
“has will tD Ct Date: q/ af Lo LG
Signature:
Title: LY, etait. Din tLlor
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