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Appendix B: Short Environmental Assessment Form

  1. Instructions for Completing

  2. 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.

  3. 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.

  4. Part 1 - Project and Sponsor Information

  5. 1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance, administrative rule, or regulation?

  6. 2. Does the proposed action require a permit, approval, or funding from any other governmental agency?

  7. 4. Check all land uses that occur on, adjoining and near proposed action.

  8. 5. Is the proposed action,

  9. a. A permitted use under the zoning regulations?

  10. b. Consistant with the adopted comprehensive plan?

  11. 6. Is the proposed action consistant with the predominant character of the existing build or natural landscape?

  12. 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Enviornmental Area?

  13. 8a. Will the proposed action result in a substantial increase in traffic above present levels?

  14. 8b. Are public transportation service(s) available at or near the site of the proposed action?

  15. 8c. Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action?

  16. 9. Does the proposed action meet or exceed the state energy code requirements?

  17. 10. Will the proposed action connect to an existing public/private water supply?

  18. 11. Will the proposed action connect to existing wastewater utilities?

  19. 12a. Does the site contain a structure that is listed on either the State or National Register of Historic Places?

  20. 12b. Is the proposed action located in an archaeological sensitive area?

  21. 13a. 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?

  22. 13b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody?

  23. 14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply:

  24. 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?

  25. 16. Is this project site located in the 100 year flood plan?

  26. 17. Will the proposed action create storm water discharge, either from point or non-point surfaces?

  27. 17a. Will storm water discharges flow to adjacent properties?

  28. 17b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?

  29. 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)?

  30. 19. Has the site of the proposed action or an adjoining property been the location of an active or close solid waste management facility?

  31. 20. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or completed) for hazardous waste?


  33. Zoning Board to Fill out. Applicant does not fill out Part 2.

  34. 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 Part1 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?"

  35. 1. Will the proposed action create a material conflict with an adopted land use plan or zoning regulations?

  36. 2. Will the proposed action result in a change in the use or intensity of use of land?

  37. 3. Will the proposed action impair the character or quality of the existing community?

  38. 4. Will the proposed action have an impact on the enviornmental characteristics that caused the establishment of a Critical Enviornmental Area (CEA)?

  39. 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?

  40. 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?

  41. 7. Will the proposed action impact existing:

  42. 7a. Public / Private water supplies?

  43. 7b. Public / Private wastewater treatment utilities?

  44. 8. Will the proposed action impair the character of quality of important historic, archaeological, architectural or aesthetic resources?

  45. 9. Will the proposed action result in an adverse change to natural resources (e.g. wetlands, waterbodies, groundwater, air quality, flora and fauna)?

  46. 10. Will the proposed action result in an increase in the potential for erosion, flooding, or drainage problems?

  47. 11. Will the proposed action create a hazard to enviornmental resouces or human health?

  48. Part 3 - Determination of significance.The Lead Agency is responsible for the completion of Part 3.

  49. For every question in Part 2 that was answered "moderate to large impact may occur", or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse enviornmental impact, please complete Part 3. Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting. Probability of occuring, duration, irreversibility, geographic scope and magnitude. Also consider the potential for short term, long term and cumulative impacts.

  50. Decision

  51. Leave This Blank:

  52. This field is not part of the form submission.