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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: |
[]Shoreline [E] Forest [7] Agricultural/grasslands [[] Early mid-successional
[Wetland [] Urban $f Suburban
{5. 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
17. Will the proposed action create storm water discharge, either from point or non-point sources? NO | YES
If Yes,
ooo
a. Will storm water discharges flow to adjacent properties?
b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?
Lf Yes, briefly describe:
i8. Does the proposed action include construction or other activities that would result in the impoundment of water
or other liquids (e.g.,. retention pond, waste lagoon, dam)?
if Yes, explain the purpose and size of the impoundment:
19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste 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 YES
completed) for hazardous waste?
If Yes, describe: =
1 CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF
MY KNOWLEDGE
Applicant/sponsor/name: “A | _ Date: \-29-Z20
Signature: _ Title OLIN K
PRINT FORM DePeitlsner ROF aeE EE L
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