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s Short Environmental Assessment Form Part I ~ Project Information Instructions for Completing Part [ ~ 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 mformation which you believe will be needed by or useful to the lead agency; attach additional pages as necessary to supplement any iter. Part 1 — Project and Sponsor Information Name of Action or Project: Dos, wash * GAGE ArAGTSAT Project Location (describe, and attach a location map): SSB Wsthio Brief Description of Proposed Action: Papen pesa. wae ara his Name of Applicant or Sponsor: i Ug _ bsS2- F02Y Telephoner ¥ 0x. Borming hon. Ete Lerman Address: 458 Rorttalls RA. City/PO: State; Zip Code: Eos Aucoad SY j4oso I. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, NO YES administrative rule, or regulation? If Yea, attach a natrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2, [fno, continue to question 2, 2. Does the proposed action require a permit, approval or funding from any other government Agency? If Yes, list agency(s) name and permit or approval: 3. a. Total acreage of the site of the proposed action? ( b. Total acreage to be physically disturbed? OS acres c, Total acreage (project site and any contiguous properties) owned or controlled by the applicant or project sponsor? i Aa acres 4, Check alf land uses that occur on, are adjoining or near the proposed action: [}Urban [—] Rural (non-agriculture) [1 Industrial ef Commercial [7] Residential (suburban) [] Fores: (1) Agticulture [] Aquatic [7] Other(Specify): [_] Parkland Pape bof 3 SEAF 2019