00472rZ., r.,. ,..t �: •! ylr y, r f'a �.l.'.i h i r i}if': `•'t i � .i �' P Y k n YC,+r' +1° i.f tiiS�tNq dr � af '
c; t u� t . ! at r t A` , k . .; t _ .• �1 i i - u r a � 1 , � \ 5,. '�, �j f'r.
• Yes M be no
1 (17) llutnnn lIc•,lth. Will the }pro osal 2
• p
rc�
2 a,u=E m ffic creation of ;any :>
3 health hazard or potential health
�r.
41 hazard (excluding mental health)?
G Explanation: GK`,
7,
8 fit;
` 9 (18) Artheti c. . Will the proposal �t
10! rc:s;:u7--iii Llte obstruction of any
111 scenic vista or view open to the
121 public or will the proposal re-
13i sult in t ho creation of ill
14 aesthetically offensive site open nl
�y
15 to public view? X;
16-
17 Explanation : 4?.
18
19
20 (19) I:c,cr cation, Will the proposal ���
21. rrr11 .a ii an impact upon the
29 quality ur quantity of existing r ,.
23 rcecrcaLi011 opportunities? .X_. tilt.•
24
25 Explzuati.on : r `'
26
27 - '}
28I (20) At cl c i�10-i cal /Ili t ori.cal . Will the
29 prul�ns.:) t:;,sult zn an a7tcrati.on of
30 a sif;i��.fi.cant tircliaological or his }
31 torical :ice, structure, object
32 or building? X .
33
34 Explanation:
35
36
37 1II.. SIGNATURE
3a
39 I, 'the wider;iE;nc�d, �tatc that to the best of illy 1,nowledge
40 the above infortnt�ti.u:t is tru,.' and cou:l)lct.e. It is understood t
41. that the lChd agdncy: nay a•:iLlIldraw aruy .declaraLi.on u: mmn-si&l1i-
42 ficance Lltat i.t mij,,ht issue in reliance upon this checklist
43 should there be any misrepresentation or ck o£ f 1 disclour 5
44 on my part. ;
45 i
46 Proponen
47
48 4lAC 1�)7-] 0-37U WIT-RD1'U11di+1. 0)' AFFI11;/LYING 1'llR]iS110LI)
49 AI:TL'It'1i�;A*T-1* . IT at tiny time after the entry of a declara- 11
50 Lion of siFnifi.cance�, the proponent modifies the proposal '
51 so that, in the judvmont of die load agency, .all significant s�
5,) adverse cnvironu«ental i.i�pacts 1,-c:,ul.tinc, therefrom arc- elimin- ik
53 at<ed the declaration of, • , significance .Mill be 4;ithdralJil 1f
54 and a dcclaratimn of. non-siFttir:icance entered instead. The
5 load agency shall al::o revise Lhe registcr.s at its SLNA '
56 }public information ccnt:er accordingly. If the pro Ij
57 ponent of a Proposal. is a private applicant, he proposal
58 shall not be considered modified until all lictense applica-
59 tions for Lhe proposal are revised to reflect the modification.
1. �: