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16114 75TH PL W
STREET.FILE-��
ENVIRONMENTAL CHECKLIST
A. BACKGROUND
1. Name of Proponent
2.
3. bate Checkl i st Submi tted 6�— /3 —6 �
4. Agency .Requiring Checklist e',Ty, mF eoAla &pS
5. Name of Proposal, if applicable
APR 13 1g84
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6. Nature and Brief Description of 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:
7. Location of Proposal (describe the physical setting of the proposal, as
well as the extent of the land area affected by any environmental im-
pacts, including any other information needed to give an accurate under-
standing of the environmental setting of the proposal):
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8. Estimated Date for Completion of the Proposal&
9. List of all Permits,'Licenses, or Government Approvals Required for all
Proposal (federal, state, and local — including rezones):
10. Do you have any plans for future additions, expansions, or further
activity related to or connected with this proposal? If yes, explain.
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:
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APR 13.19
B.
ENVIRONMENTAL IMPACTS (Explanations of all "yes" and "maybe" answers are required).
YES MAYBE NO
1.
Earth. Will the proposal result in:
a. Unstable earth conditions or in changes
in geologic substructures?
b. Disruptions, displacements, compaction
or overcovering of the soil?
c. Change in topography or ground surface
relief features?
d. The destruction, covering or modifica-
tion of any unique geologic or physical
features?
e. Any increase in wind or water erosion
of soils, either.on or off the site?
f. Changes in deposition or erosion of
beach sands, or changes in siltation,
deposition or erosion which may modify
the channel or a river or stream or the
bed of the ocean or any bay, inlet or
lake?
Explanation:
x
2. Air. Will the proposal result in:
a. Air emissions or deterioration of
ambient air quality?
X
b. The creation of objectionable odors?
c. Alteration of air movement, moisture
or temperature, or any change in climate,
either locally or regionally?
Explanation:
3. Water. Will the proposal result in:
a. Changes in currents, or the course
or direction of water movements, in either
marine or fresh waters?
X
b. Changes in absorption rates, drainage
patterns, or the rate and amount of sur-
face water runoff?
x
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APR 131984
c. Alterations to the course or flow
of flood waters?
d. Change in the amount of surface water
in any water body?
e. Discharge into surface waters, or in
any alteration of surface water quality,
including but not limited to temperature,
dissolved oxygen or turbidity?
f. Alteration of the direction or.rate
of flow of ground waters?
g. Change in the quantity of ground
waters, either through direct additions
or withdrawals, or through interception
of an aquifer by cuts or excavations?
h. Deterioration in ground water quality,
either through direct injection, or through
the seepage of leachate, phosphates, deter-
gents, waterborne virus or bacteria, or
other substances into the ground waters?
i. Reduction in the amount of water
otherwise available for public water
supplies?
Explanation:
4. Flora. Will the proposal result in:
a. Change in the diversity of species,
or numbers of any species of flora (in-
cluding trees, shrubs, grass, crops,
microflora and aquatic plants)?
b. Reduction of the numbers of any
unique, rare or endangered species
of flora?
c. Introduction of new species of
flora into an area, or in a barrier
to -the normal replenishment of exist-
- ing species?
d. Recution in acreage of any agri-
cultural crop?
Explanation:
YES MAYBE NO
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APR 131984
YES
MAYBE NO
5. Fauna. WIll the proposal result in:
a. Changes in the diversity of species,
or numbers of any species of fauna (birds,
land animals including reptiles, fish and
shellfish, benthic organisms, insects or
microfauna)?
X
b. Reduction of the numbers of any
unique, rare or endangered species
of fauna?
c. Introduction of new species of
fauna into an area, or result in a
barrier to the migration or movement
of fauna?
d. Deterioration to existing fish or
wildlife habitat?
RE
7.
91
Explanation:
Noise. Will the proposal increase
existing noise levels?
Explanation:
Light and Glare. Will the proposal
produce new fight or glare?
Explanation:
Land Use. Will the proposal result
in the alteration of the present or
planned land use of an area?
Explanation:
9.� Natural Resources. Will the proposal
result in:
a. Increase in the rate of use of any
natural resource?
b. Depletion of any nonrenewable
natural resource?
Explanation:
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APR 131984
YES MAYBE NO
10. Risk of Upset. Does the proposal involve
a risk of an explosion or release of hazard-
ous substances (including, but not limited
to, oil, pesticides, chemicals or radiation)
in the event of an accident or upset condi-
tions? �C
Explanation:
11. Population. Will the proposal alter the
To�cation, distribution, density, or growth
rate of the human population of an area? X
Explanation:
12. Housing. Will the proposal affect existing
housing, or create a demand for additional
housing?
Explanation:
13. Transportation/Circulation. Will the pro-
posal result in:
X
a. Generation of additional vehicular
movement? X
b. Effects on existing parking facili-
ties, or demand for new parking? SC
c. Impact upon existing transportation
systems?
d. Alterations to present patterns of
circulation or movement of people and/or
goods? �C
e. Alterations to waterborne, rail or
air traffic? �C
f. Increase in traffic hazards to motor
vehicles, bicyclists or pedestrians?
Explanation:
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YES MAYBE NO APR 131984
14.
Public Services. Will the proposal have
an effect upon, or result in a need for
new or altered governmental services in
any of the following areas:
a. Fire protection?
b. Police protection?
c. Schools?
d. Parks or other recreational
facilities?
e. Maintenance of public facilities,
including roads?
f. Other governmental services?
Explanation:
X
X
X
15. Energy. Will the proposal result in:
a. Use of substantial amounts of fuel
or energy?
is
b. Demand upon existing sources of
energy, or require the development
of new sources of energy?
Explanation:
16. Utilities. Will the proposal result in
as ne�ior new systems or alterations to
the following utilities:
a. Power or natural gas?
b. Communications systems?
X
c. Water?
>C
d. Sewer or septic tanks?
e. Storm water drainage?
)C-
f. Solid waste and disposal?
" X
Explanation:
10
,APR 1Z,1984
YES MAYBE NO
17. Human Health. Will the proposal result
in the creation of any health hazard or
potential health hazard (excluding
mental health)?
Explanation:
18. Aesthetics. Will the proposal result
in the obstruction of any scenic vista
or view open to the public, or will the
proposal result in the creation of an
aesthetically offensive site open to
public view? fC
Explanation:
19. Recreation. Will the proposal result
in an impact upon the quality or quan-
tity of existing recreational oppor-
tunities?
Explanation:
20. Archeological/Historical. Will the
proposal result in an alteration of
a significant archeological or his-
torical site, structure, object or
building?
Explanation:
C. SIGNATURE
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
or non -significance 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 Ns�0KCC�
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