Part 1 – Project and Sponsor 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 an 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.

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Name of Action or Project *

Project Location *

Brief Description of Proposed Action *

Name of Applicant or Sponsor *

First

Last

Phone Number *

Email *

Email

Confirm Email

Address

Address Line 1

Address Line 2

City

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Zip Code

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

• Yes
• No

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

• Yes
• No

2b. If “yes,” list agency(s) name and permit approval: *

3a. Total acreage of the site of the proposed action? *

3b. Total acreage to be physically disturbed? *

3c. 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, are adjoining or near the proposed action: *

• Urban
• Rural (non-agriculture)
• Industrial
• Commercial
• Residential (suburban)
• Forest
• Agriculture
• Parkland
• Aquatic
• Other

If “other,” please specify: *

5a. Is the proposed action a permitted use under the zoning regulations? *

• Yes
• No
• N/A

5b. Is the proposed action consistent with the adopted comprehensive plan? *

• Yes
• No
• N/A

6. Is the proposed action consistent with the predominant character of the existing built or natural landscape? *

• Yes
• No

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

• Yes
• No

If “yes,” please identify: *

proposed site transportation

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

• Yes
• No

8b. Are public transportation services available at or near the site of the proposed action? *

• Yes
• No

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

• Yes
• No

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

• Meet
• Exceeds

9b. If the proposed action will exceed requirements, describe design features and technologies: *

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

• Yes
• No

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

• Yes
• No

11b. If "no," describe method for providing potable water: *

12a. Does the site contain, or is it substantially contiguous to, a building, archeological site, or district which is listed on the National or State Register of Historic Places, or that has been determined by the Commissioner of the NYS Office of Parks, Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places? *

• Yes
• No

12b. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for archeological sites on the NY State Historic Preservation Office (SHPO) archeological site inventory? *

• Yes
• No

13a. Does any portion of the proposed action, or lands adjoining the proposed action, contain wetlands or other waterbodies regulated by a federal, state, or local agency? *

• Yes
• No

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

• Yes
• No

13c. If “yes,” identify the wetland or waterbody and extent of alteration in square feet or acres: *

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

• Shoreline
• Forest
• Agricultural/Grasslands
• Early mid-successional
• Wetland
• Urban
• Suburban

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? *

• Yes
• No

16. Is the project site located in the 100-year floodplain? *

• Yes
• No

17a. Will the proposed action create storm water discharge, either from point or non-point sources? *

• Yes
• No

17b. If you answered “yes” to 17a, will storm water discharges flow to adjacent properties? *

• Yes
• No

17c. If you answered “yes” to 17a, will storm water discharges be directed to established conveyance systems (runoff and storm drains)? *

• Yes
• No

17d. If you answered “yes” to 17b, or 17c, please briefly describe: *

18a. Does the proposed action include construction other activities that would result in the impoundment of water or other liquids (e.g., retention pond, waste lagoon, dam)? *

• Yes
• No

18b. If “yes,” explain the purpose and size of the impoundment: *

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

• Yes
• No

19b. If “yes,” describe: *

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

• Yes
• No

20b. If “yes,” describe:

CERTIFICATION OF INFORMATION ACCURACY *

• I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

Today's Date *

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