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14. Identity the typical habitat types that occur on, or are likely 10 be found on the project site. Check all that apply []Shoreline [1] Forest [[] Agriculiural/grasslands [[] Early mid-successional ClWetland [[] Urban $3 Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or Federal government as threatened or endangered? NO YES 16. Is the project site located in the 100-year flood plan? NO gl NO x 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)? Mm Lf Yes, briefly describe: 18. Does the proposed action include construction or other activities that would result in the impoundment of water or other liquids (¢.g...retention pond, waste lagoon, dam)? xO if Yes, explain the purpose and size of the impoundment; 19, Has the site of the proposed action or an adjaining property been the location of an active or closed solid waste NO | YES inanagement facility? If Yes, describe: CI 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? Lf Yes, describe: KC I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor/name: Date: “\-2¢7-7 gy Signature: We Quine | PRINT FORM Jape 3 of 3