01141 (2)}
Yes Maybe No
1
(17) Human
llval.��! Will the pi aposal
'2
iesult
iii t'.• creation of any ,.
3
health
hazard or potential health
1a
4
hazard
(excluding mental health)? �C
5
6I
Explanation:
7
H
9� (18) Aesthetics. Will the proposal
'? 10
result in the obstruction of any
11
scenic vista or view open to the
12
public, or will the proposal re-
13
sult in the creation of an '
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aesthetically offensive site open
y,
15
to public view?
`z 16
17
18
Explanation: 47—r11C7-
19
f.
20
(19) Recreation. Will the proposal
JR 21
resu=Ui an impact upon the
,V 22
quality.or quantity of existing
sa;
23
recreational opportunities?
a 24
25
Explanation:
26
;
27
28
�(20) Arclirolo ical./IliStorical. Will the
#f 29
proposal refit in an alteration of
30
a significant archeological or his-
31
torical site, structure, object
32
33
or building?.
34
Explanation.:
35
36
37
III. SIGNATURE
;
t� 38
39
I. the undersigned, state that to the best of my knowledge
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the above information is.true and complete. It is understood
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that the lead ag+,ency•may withdraw any declaration of non-signi-
42
ficance'that it might issue in reliance upon this checklist
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should'there be any misrepresentation or lack of full disclosure
44
on my part . .
45
46
Proponent:
47
48
WAC 1197-1.0-370 WITHDRAWAL OF AFFIRMATIVE TIIRES11OLD
49
DFTE1611HATIONV. If at .any time after the entry of a declara-
R`
50
tion of significance, the proponent modifies -Hie proposal
51
so that, in the ,judgment of the leas agency, all significant
4. 52
adverse environmental impacts resulting; therefrom are elimin-'.
s 53
ated, the declaration of significance Tall be withdrawn
54
and a declaration of non -significance enteredThe
55
5G
.instead.
lend agency shall also revise the registers at its SEPA
public information.center accordingly, if the
57
pro-
poiiimt of a proposal is a private applicant, the proposal
58
59
shall not be considered modified until all license applica-
i
tions for..the proposal are revised to reflect the modification.
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