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617.20
Appendix B
Short Environmental Assessment Form
Instructions for Completing
Part 1 - Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become part of the application for approval or funding, are subject to public review, and may be subject to further verification.
Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully
respond to any item, please answer as thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful
to the lead agency; attach additional pages as necessary to supplement any item.
Part 1 - Project and Sponsor Information
S lee) On ) feperty. im dora t- of exits GAA IYC
Name of Action or Project:
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Project Location (describe, and attach a location map):
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Brief Description of Proposéd Action:
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Name of Applicant or Sponsor: Telephone: 7 { b-20°- Yol¢
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Address: 7 uv
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City/PO: State: Zip Code:
1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, -
AJY | 14139 NO | YES
administrative rule, or regulation?
If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that \K
may be affected in the municipality and proceed to Part 2. If no, continue to question 2.
2. Does the proposed action require a permit, approval or funding from any other governmental Agency? NO_| YES
If Yes, list agency(s) name and permit or approval:
3.a. Total acreage of the site of the proposed action? a 3 acres
b. Total acreage to be physically disturbed? acres
c. Total acreage (project site and any contiguous properties) owned —
or controlled by the applicant or project sponsor? “ A 45 __acres
4. Check all land uses that occur on, adjoining and near the proposed action.
Q Urban Rural (non-agriculture) © Industrial © Commercial 2 Residential (suburban)
(Forest © Agriculture © Aquatic ( Other (specify):
O Parkland
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