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14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply: □Shoreline □ ✔ Forest Agricultural/grasslands Early mid-successional ✔ Wetland □ Urban ✔ Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or NO YES Federal government as threatened or endangered? ✔ 16. Is the project site located in the 100-year flood plan? NO YES ✔ NO YES 17. Will the proposed action create storm water discharge, either from point or non-point sources? If Yes, ✔ a. Will storm water discharges flow to adjacent properties? ✔ b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)? ✔ If Yes, briefly describe: _____________________________________________________________________________________________ Storm water runoff will be conveyed to an existing on-site ditch. _____________________________________________________________________________________________ 18. Does the proposed action include construction or other activities that would result in the impoundment of water NO YES or other liquids (e.g., retention pond, waste lagoon, dam)? If Yes, explain the purpose and size of the impoundment:______________________________________________ Storm water detention area(s) will be designed in accordance with local and State requirements. ✔ ____________________________________________________________________________________________ _ Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste 19. NO YES management facility? If Yes, describe: _______________________________________________________________________________ ✔ _____________________________________________________________________________________________ 20.Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or NO YES completed) for hazardous waste? If Yes, describe: _______________________________________________________________________________ ✔ _____________________________________________________________________________________________ I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: ____________________________________________________ Anthony J. Pandolfe, PE Date: 12/23/25 __________________________ _____________________ Project Engineer Signature: _____________________________________________________Title:__________________________________ PRINT FORM Page 3 of 3 Page 33 of 192