HomeMy WebLinkAboutEnvironmental Checklist Form - SEP Application - 4/23/1982r
E.R. No.
Introduction: The State Environmental Policy Act of 1971, Chapter
43.21C, RCW, requires all state and local governmental agencies to
consider environmental values both for their own actions and when
licensing private proposals. The Act also requires that an EIS be
prepared for all major actions significantly affecting the quality
of the environment. The purpose of this checklist is to help the
agencies involved determine whether or not a proposal is such a
major action.
Please answer the following questions as completely as you can
with the information presently available to you. Where explana-
tions of your answers are required, or where you believe an ex-
planation would be helpful to government decision makers, include
your explanation in the space provided, or use additional pages if
necessary. You should include references to any reports or
studies of which you are aware and which are relevant to the
answers you provide. Complete answers to these questions will
help all agencies involved with your proposal to undertake the
required environmental review without unnecessary delay.
The following questions apply to your total proposal, not just to
the license for which you are currently applying or the proposal
for which approval is sought. Your answers should include the
impacts which will be caused by your proposal when it is complet-
ed, even though completion may not occur until sometime in the
future. This will allow all of the agencies which will be
involved to complete their environmental review now, without
duplicating paper�,7ork in the future.
NOTE: This is a standard form being used by all state and local
agencies in the State of Washington for various types of nropos-
als. Nany of the questions may not apply to your proposal. If a
question does not apply, just answer it "no" and continue on the
the next question.
ENVIROT91ENTAL C3ECKLIST FORM
I BACKGROUND
1. Name of Prononent ( L�� ��/ ���k
2. Address and phone number of proponent :
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3. Date Checklist Submitted 'j 2 3— �Z
4. Agency Requiring Checklist
5. ?Fame of Proposal, if applicable:
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6. Nature and Brief Description of the Proposal (including
but not limited to its size, general design elements, and
other factors that will give an accurate understanding of
its scope and nature) : /
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7. Location
c tion of Proposal (describe the physical setting of
the proposal, as well as the extent of the land area
affected by any environmental impacts, including any
other information needed to give an accurate understand-
ing of the environmental setting of the proposal) :
T-6 r '-- iprsP. Estimated Date for Completion of the Proposal:
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9. List of all Permits, Licenses or Government Approvals
P.equired for the Proposal (federal, state and
local--including rezones) :
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10. Do you have any plans for future additions, expansion, or
further activity related to or connected with this
proposal? If yes, explain:
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11. Do you know of any plans by others which may affect the
property covered by your proposal? If yes, explain:
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12. Attach any other application form that has been completed
regarding the proposal; if none has been completed, but
is expected to be filed at some future date, describe the
nature of such application form:
I, the undersigned, state that to the best of my knowledge
the above information is true and complete. It is understood that
the lead agency may withdraw any declaration of non-sienificance
that it might issue in reliance upon this checklist should there
be any willful misrepresentation or willful lack of full
disclosure on my part.
Proponent
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✓' ?UE: To cover the Environmental Review, a cheY for $30, made
payable to the Mason Regional Planning Council, should accompany
the Checklist at tine of submittal.