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Case# 19-f/
F.xhibit # ~
Short Environmental Assessment Form Date t:£ f 7iUi
Part 1 - Project Information
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
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Name of Applicant or Sponsor: Telephone: 7 ll.Q - 8CO- 103,5
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Address:
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City!PO: k;- ~\) 'O'fO..., State: f...)l.{ ZipCl4l)
1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, NO YES
administrative rule, or regulation?
If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that
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 government Agency? NO YES
If Yes, list agency(s) name and permit or approval:
11)
3. a. Total acreage of the site of the proposed action?
b. Total acreage to be physically disturbed?
c. Total acreage (project site and any contiguous properties) owned
or controlled by the applicant or project sponsor? ,. ~ b acres
4. Check all land uses that occur on, are adjoining or near the proposed action:
D Urban ~ Rural (non-agriculture) D Industrial D Commercial ~ Residential (suburban)
D Forest O Agriculture 0 Aquatic D Other(Specify):
□ Parkland
Page 1 of 3 SEAF 2019