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I4, Identify the typloal habliat types that occtn' on, ox are likely to be found on the project site. Check all that apply: C"TShoreline [7] Fotest [7] Agticultural/grassiands [7] Barly mid-successtonat CTWetland = [] Urban (74 Suburban (5. Does the site of the proposed action contain any species of animal, or assoolated habitats, listed by Federal government as threatened or etidangered? the State or NO | YES im Cy] 16. Is the project atte located in the 100-year flood plan? NO | YES . \7, Will the proposed action create storm water : either from point or non-point ~ lf Yes, discharge, sources? NO | YES —-— [| x a Will storm water discharges flow to adjacent properties? ly] [| b, Will storm water discharges be directed to astablished If Yes, briefly deseribe: conveyance systems (runoff and storm drains)? [| | \ | Ly] i; ff fe Loc WM Water wll ow to AAjale I Storm Z ra (ns. 18, Does the proposed action Include construction or other actlvities that would result in the impoundment of water or other liquids (e.g, retention pond, waste lagoon, dam)? |NO | YES If Yes, explain the purpose and size of the impoundmen t: 49, Has the site of the proposed action or an adjoin ing property been the location of an active ot closed management facility? solid waste | NO } YES If Yes, describe: | Al} 20.Aas the site of the proposed action or an adjoining proparty been the subject of remediation (ongoing or completed) for hazardous waste? NO YES If Yes, desoribe: eee mie T CERTIFY THAT THE INFORMATION PROV MY KNOWLEDGE IDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF Appticant/ ; F LL HD é Date: gf q[. L OLE Signature: _ritt Sxecative. Director — PRINT FORM | Page 3 of 3