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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 YES
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: _______________________________________________________
Part 2 - Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following
questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept “Have my
responses been reasonable considering the scale and context of the proposed action?”
No, or
small
impact
may
occur
Moderate
to large
impact
may
occur
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 community?
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, archaeological,
architectural or aesthetic resources?
9. Will the proposed action result in an adverse change to natural resources (e.g., wetlands,
waterbodies, groundwater, air quality, flora and fauna)?
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔