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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 Name of Action or Project: Project Location (describe, and attach a location map): Brief Description of Proposed Action: Name of Applicant or Sponsor: Telephone: E-Mail: Address: City/PO: State: Zip Code: 1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, N administrative rule, or regulation? If Yes, attach a narrative description of the intent of the proposed action and the environmental r may be affected in the municipality and proceed to Part 2. If no, continue to question 2. esources t O hat YES 2. Does the proposed action require a permit, approval or funding from any other governmental A Yes, list ag gency? If ency(s) name and permit or approval: O N YES 3.a. Total acreage of the site of the proposed action? 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? 4. Check all land uses that occur on, adjoining and near the proposed action. 9 Urban 9 Rural (non-agriculture) 9 Industrial 9 Commercial 9 Residential (suburban) 9 Forest 9 Agriculture 9 Aquatic 9 Other (specify): 9 Parkland Page 1 of 4 Not effective until October 7, 2013 ---PAGE BREAK--- 5. Is the proposed action, a. A permitted use under the zoning regulations? NO S b. Consistent with the adopted comprehensive plan? YE N/A 6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? NO YES 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental A If Yes, identify: _ rea O ? N _ YES 8. a. Will the proposed action result in a substantial increase in traffic above present levels? sed action NO YES b. Are public transportation service(s) available at or near the site of the proposed action? c. Are any pedestrian accommodations or bicycle routes available on or near site of the propo ? 9. Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements, describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? If Yes, does the existing system have capacity to provide service? NO YES If No, describe method for providing potable water: NO ES Y NO ES Y 11. Will the proposed action connect to existing wastewater utilities? If Yes, does the existing system have capacity to provi If No, describe method for providing wastewate de service? NO YES r treatment: NO 12. a. Does the site contain a structure that is listed on either the State or National Register of Historic Places? Is the proposed action located in an archeological sensitive are b. a? YES 13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain wetlands or other waterbodies regulated by a federal, state or local agency? b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody? identify th If Yes, e wetland or waterbody and extent of alterations in square feet or acres: NO YES 14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all t l hat app y: mid-successional Shoreline Forest Agricultural/grasslands Early Wetland Urban Suburban 15. Does the site of the proposed action contain any species of animal, or associated habitats, listed NO YES by the State or Federal government as threatened or endangered? NO YES 16. Is the project site located in the 100 year flood plain? 17. Will the proposed action create storm water discharge, either from point or non-point sources? NO If Yes, s? NO YES . Will storm water discharges cent propertie a flow to adja s) If Y NO YES YES b. Will storm water discharges be directed to established conveyance systems (runoff and storm drain ? es, briefly describe: Page 2 of 4 Not effective until October 7, 2013 ---PAGE BREAK--- 18. Does the proposed action include construction or other activities that result in the impoundment of water or other liquids (e.g. retention pond, waste lagoon, dam)? If Yes, explain purpose and size: NO YES 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste management facility? If Yes, describe: NO ES Y 20. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or completed) for hazardous waste? If Yes, describe: NO YES I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor name: Date: Signature: 2. Answer a of the f llowing t s or o oncept “Have my Part 2 - Impact Assessment. The Lead Agency is responsible for the completion of Part questions in Part 2 using the information contained in Part 1 and other materials submitted b ll pons o r y the projec otherwise available to the reviewer. When answering the questions the reviewer should be guided by the c responses been reasonable considering the scale and context of the proposed action?” No sm ll impact may Mo large ct may occur , or a occur derate to impa 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? 3. Will the proposed action impair the character or quality of the existing commu ty? ni 4. Will the proposed action have an impact on the environmental characteristics that caused the establishment of a Critical Environmental Area (CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or affect existing infrastructure for mass transit, biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: a. public / private water supplies? b. public / private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic, arch aeological, architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources wetlands, waterbodies, groundwater, air quality, flora and fauna)? Page 3 of 4 Not effective until October 7, 2013 ---PAGE BREAK--- Page 4 of 4 No, or small impact may occur Moderate to large impact may occur 10. Will the proposed action result in an increase in the potential for erosion, flooding problems? o rainage r d 11. s or human health? Will the proposed action create a hazard to environmental resource Part 3 - Determination of significance. The Lead Agency is responsible for th stion in Part 2 that was answered “moderate to large impact may occur”, or i ent of the propo e completion of Part 3. For every que f there is a need to explain why particular elem sed action may or will not result in a significant adverse environmental impact, please complete Part 3. pact, including any measures or design elements that have been included by e proje c . Part 3 should also explain how t gency determined that the impact may or w ssed onsidering its setting, pro ability of occurring, duration nsider the potential for short-term, long-term and a Part 3 should, in sufficient detail, identify the im th ct sponsor to avoid or reduce impa ts he lead a ill not be significant. Each potential impact should be asse c , irreversibility, geographic scope and magnitude. Also co b cumulative impacts. 9 Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. 9 Check this box if you have determined, based on the information and analysis above, and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Name of Lead Agency Date Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from Responsible Officer) Not effective until October 7, 2013