APPENDIX G
ENVIRONMENTAL CHECKLIST FORM
NOTE: The following is a sample form that may be tailored to satisfy individual agencies’ needs
and project circumstances. It may be used to meet the requirements for an initial study when the
criteria set forth in CEQA Guidelines have been met. Substantial evidence of potential impacts
that are not listed on this form must also be considered. The sample questions in this form are
intended to encourage thoughtful assessment of impacts, and do not necessarily represent
thresholds of significance.
1. Project title: _______________________________________________________________
2. Lead agency name and address:
____________________________________________________________________________
____________________________________________________________________________
3. Cont
act person and phone number: ____________________________________________
4. Project location: ___________________________________________________________
5. Project sponsor's name and address:
____________________________________________________________________________
____________________________________________________________________________
6. G
eneral plan designation: ___________________________
7. Zoning: ________________________
8. Description of project: (Describe the whole action involved, including but not limited to later
phases of the project, and any secondary, support, or off-site features necessary for its
implementation. Attach additional sheets if necessary.)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
9. Surrounding land uses and setting: (Briefly describe the project's surroundings)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page 1
10. Other public agencies whose approval is required: (e.g., permits, financing approval, or
participation agreement.)
_________________________________________________________________________
_________________________________________________________________________
11. H
ave California Native American tribes traditionally and culturally affiliated with the project
area requested consultation pursuant to Public Resources Code section 21080.3.1? If so, is
there a plan for consultation that includes, for example, the determination of significance of
impacts to tribal cultural resources, procedures regarding confidentiality, etc.?
_________________________________________________________________________
_________________________________________________________________________
NOTE: Conducting consultation early in the CEQA process allows tribal governments, lead agencies, and project
proponents to discuss the level of environmental review, identify and address potential adverse impacts to tribal
cultural resources, and reduce the potential for delay and conflict in the environmental review process. (See
Public Resources Code section 21080.3.2.) Information may also be available from the California Native
American Heritage Commission’s Sacred Lands File per Public Resources Code section 5097.96 and the
California Historical Resources Information System administered by the California Office of Historic Preservation.
Please also note that Public Resources Code section 21082.3(c) contains provisions specific to confidentiality.
Page 2
EN
VIRONMENTAL FACTORS POTENTIALLY AFFECTED:
The environmental factors checked below would be potentially affected by this project, involving
at least one impact that is a “Potentially Significant Impact,” as indicated by the checklist on the
following pages.
Aesthetics
Biological Resources
Geology/Soils
Hydrology/Water Quality
Noise
Recreation
Utilities / Service Systems
Agriculture / Forestry
Resources
Cultural Resources
Greenhouse Gas Emissions
Land Use / Planning
Population / Housing
Transportation
Wildfire
Air Quality
Energy
Hazards and Hazardous
Materials
Mineral Resources
Public Services
Tribal Cultural Resources
Mandatory Findings of
Significance
DETER
MINATION
On the basis of this initial evaluation:
I find that the proposed project COULD NOT have a significant effect on the environment, and a
NEGATIVE DECLARATION will be prepared.
I find that although the proposed project could have a significant effect on the environment, there
will not be a significant effect in this case because revisions in the project have been made by or agreed
to by the project proponent. A MITIGATED NEGATIVE DECLARATION will be prepared.
I find that the proposed project MAY have a significant effect on the environment, and an
ENVIRONMENTAL IMPACT REPORT is required.
I find that the proposed project MAY have a “potentially significant impact” or “potentially significant
unless mitigated” impact on the environment, but at least one effect 1) has been adequately analyzed in
an earlier document pursuant to applicable legal standards, and 2) has been addressed by mitigation
measures based on the earlier analysis as described on attached sheets. An ENVIRONMENTAL IMPACT
REPORT is required, but it must analyze only the effects that remain to be addressed.
I find that although the proposed project could have a significant effect on the environment,
because all potentially significant effects (a) have been analyzed adequately in an earlier EIR or
NEGATIVE DECLARATION pursuant to applicable standards, and (b) have been avoided or mitigated
pursuant to that earlier EIR or NEGATIVE DECLARATION, including revisions or mitigation measures
that are imposed upon the proposed project, nothing further is required.
Signature
Date
Page 3
EV
ALUATION OF ENVIRONMENTAL IMPACTS
1. A brief explanation is required for all answers except “No Impact” answers that are
adequately supported by t
he information sources a lead agency cites in the parentheses
following each question. ANo Impact” answer is adequately supported if the referenced
information sources show that the impact simply does not apply to projects like the one
involved (e.g., the project falls outside a fault rupture zone). ANo Impact” answer should be
explained where it is based on project-specific factors, as well as general standards (e.g.,
the project would not expose sensitive receptors to pollutants, based on a project-specific
screening analysis).
2. All answers must take account of the whole action involved, including off-site as well as on-
site, cumulative as well as project-level, indirect as well as direct, and construction as well
as operational impacts.
3. Once the lead agency has determined that a particular physical impact may occur, then the
checklist answers must indicate whether the impact is potentially significant, less than
significant with mitigation, or less than significant. “Potentially Significant Impact” is
appropriate if there is substantial evidence that an effect may be significant. If there are one
or more “Potentially Significant Impact” entries when the determination is made, an EIR is
required.
4. “Negative Declaration: Less Than Significant With Mitigation Incorporated” applies where
the incorporation of mitigation measures has reduced an effect from “Potentially Significant
Impact” to a “Less Than Significant Impact.” The lead agency must describe the mitigation
measures, and briefly explain how they reduce the effect to a less than significant level.
5. Earlier analyses may be used where, pursuant to the tiering, program EIR, or other CEQA
process, an effect has been adequately analyzed in an earlier EIR or negative declaration.
Section 15063(c)(3)(D). In this case, a brief discussion should identify the following:
a) Earlier Analyses Used. Identify and state where they are available for review.
b) Impacts Adequately Addressed. Identify which effects from the above checklist were
within the scope of and adequately analyzed in an earlier document pursuant to
applicable legal standards, and state whether such effects were addressed by mitigation
measures based on the earlier analysis.
c) Mitigation Measures. For effects that are “Less than Significant with Mitigation Measures
Incorporated,” describe the mitigation measures which were incorporated or refined from
the earlier document and the extent to which they address site-specific conditions for the
project.
6. Lead agencies are encouraged to incorporate into the checklist references to information
sources for potential impacts (e.g., general plans, zoning ordinances). Reference to a
previously prepared or outside document should, where appropriate, include a reference to
the page or pages where the statement is substantiated.
7. Supporting Information Sources: A source list should be attached, and other sources used
or individuals contacted should be cited in the discussion.
8. This is only a suggested form, and lead agencies are free to use different formats; however,
lead agencies should normally address the questions from this checklist that are relevant to
a project’s environmental effects in whatever format is selected.
9. The explanation of each issue should identify:
a) the significance criteria or threshold, if any, used to evaluate each question; and
b) the mitigation measure identified, if any, to reduce the impact to less than significance
Page 4
Issues
Potentially
Significant
Impact
Less Than
Significant
With
Mitigation
Incorporated
Less Than
Significant
Impact
No
Impact
a) Have a substantial adverse effect on a scenic vista?
b) Substantially damage scenic resources, including, but not
limited to, trees, rock outcroppings, and historic buildings
within a state scenic highway?
c) In nonurbanized areas, substantially degrade the existing
visual character or quality of public views of the site and its
surroundings? (Public views are those that are experienced
from publicly accessible vantage point). If the project is in an
urbanized area, would the project conflict with applicable
zoning and other regulations governing scenic quality?
d) Create a new source of substantial light or glare which would
adversely affect day or nighttime views in the area?
environmental effects, lead agencies may refer to the California Agricultural Land Evaluation and Site Assessment Model (1997)
prepared by the California Dept. of Conservation as an optional model to use in assessing impacts on agriculture and farmland. In
determining whether impacts to forest resources, including timberland, are significant environmental effects, lead agencies may refer
to information compiled by the California Department of Forestry and Fire Protection regarding the state’s inventory of forest land,
including the Forest and Range Assessment Project and the Forest Legacy Assessment project; and forest carbon measurement
a) Convert Prime Farmland, Unique Farmland, or Farmland of
Statewide Importance (Farmland), as shown on the maps
prepared pursuant to the Farmland Mapping and Monitoring
Program of the California Resources Agency, to non-
agricultural use?
b) Conflict with existing zoning for agricultural use, or a
Williamson Act contract?
c) Conflict with existing zoning for, or cause rezoning of, forest
land (as defined in Public Resources Code Section 12220(g)),
timberland (as defined by Public Resources Code
Section 4526), or timberland zoned Timberland Production (as
defined by Government Code Section 51104(g))?
d) Result in the loss of forest land or conversion of forest land to
non-forest use?
e) Involve other changes in the existing environment which, due
to their location or nature, could result in conversion of
Farmland, to non-agricultural use or conversion of forest land
to non-forest use?
a) Conflict with or obstruct implementation of the applicable air
quality plan?
b) Result in a cumulatively considerable net increase of any
criteria pollutant for which the project region is non-attainment
under an applicable federal or state ambient air quality
standard?
c) Expose sensitive receptors to substantial pollutant
concentrations?
d) Result in other emissions (such as those leading to odors)
adversely affecting a substantial number of people?
Page 5
Issues
Potentially
Significant
Impact
Less Than
Significant
With
Mitigation
Incorporated
Less Than
Significant
Impact
No
Impact
a) Have a substantial adverse effect, either directly or through
habitat modifications, on any species identified as a candidate,
sensitive, or special status species in local or regional plans,
policies, or regulations, or by the California Department of Fish
and Wildlife or U.S. Fish and Wildlife Service?
b) Have a substantial adverse effect on any riparian habitat or
other sensitive natural community identified in local or regional
plans, policies, regulations or by the California Department of
Fish and Wildlife or U.S. Fish and Wildlife Service?
c) Have a substantial adverse effect on state or federally
protected wetlands (including, but not limited to, marsh, vernal
pool, coastal, etc.) through direct removal, filling, hydrological
interruption, or other means?
d) Interfere substantially with the movement of any native
resident or migratory fish or wildlife species or with established
native resident or migratory wildlife corridors, or impede the
use of native wildlife nursery sites?
e) Conflict with any local policies or ordinances protecting
biological resources, such as a tree preservation policy or
ordinance?
f) Conflict with the provisions of an adopted Habitat
Conservation Plan, Natural Community Conservation Plan, or
other approved local, regional, or state habitat conservation
plan?
a) Cause a substantial adverse change in the significance of a
historical resource pursuant to § 15064.5?
b) Cause a substantial adverse change in the significance of an
archaeological resource pursuant to § 15064.5?
c) Disturb any human remains, including those interred outside
of dedicated cemeteries?
a) Result in potentially significant environmental impact due to
wasteful, inefficient, or unnecessary consumption of energy
resources, during project construction or operation?
b) Conflict with or obstruct a state or local plan for renewable
energy or energy efficiency?
a) Directly or indirectly cause potential substantial adverse
effects, including the risk of loss, injury, or death involving:
i) Rupture of a known earthquake fault, as delineated on
the most recent Alquist-Priolo Earthquake Fault Zoning
Map, issued by the State Geologist for the area or based
on other substantial evidence of a known fault? Refer to
Division of Mines and Geology Special Publication 42.
ii) Strong seismic ground shaking?
iii) Seismic-related ground failure, including liquefaction?
iv) Landslides?
b) Result in substantial soil erosion or the loss of topsoil?
Page 6
Issues
Potentially
Significant
Impact
Less Than
Significant
With
Mitigation
Incorporated
Less Than
Significant
Impact
No
Impact
c) Be located on a geologic unit or soil that is unstable, or that
would become unstable as a result of the project, and
potentially result in on- or off-site landslide, lateral spreading,
subsidence, liquefaction or collapse?
d) Be located on expansive soil, as defined in Table 18-1-B of
the Uniform Building Code (1994), creating substantial direct
or indirect risks to life or property?
e) Have soils incapable of adequately supporting the use of
septic tanks or alternative waste water disposal systems
where sewers are not available for the disposal of waste
water?
f) Directly or indirectly destroy a unique paleontological resource
or site or unique geologic feature?
a) Generate greenhouse gas emissions, either directly or
indirectly, that may have a significant impact on the
environment?
b) Conflict with an applicable plan, policy or regulation adopted
for the purpose of reducing the emissions of greenhouse
gases?
a) Create a significant hazard to the public or the environment
through the routine transport, use, or disposal of hazardous
materials?
b) Create a significant hazard to the public or the environment
through reasonably foreseeable upset and accident conditions
involving the release of hazardous materials into the
environment?
c) Emit hazardous emissions or handle hazardous or acutely
hazardous materials, substances, or waste within one-quarter
mile of an existing or proposed school?
d) Be located on a site which is included on a list of hazardous
materials sites compiled pursuant to Government Code
§ 65962.5 and, as a result, would it create a significant hazard
to the public or the environment?
e) For a project located within an airport land use plan or, where
such a plan has not been adopted, within two miles of a public
airport or public use airport, would the project result in a safety
hazard or excessive noise for people residing or working in the
project area?
f) Impair implementation of or physically interfere with an adopted
emergency response plan or emergency evacuation plan?
g) Expose people or structures, either directly or indirectly, to a
significant risk of loss, injury or death involving wildland fires?
a) Violate any water quality standards or waste discharge
requirements or otherwise substantially degrade surface or
ground water quality?
b) Substantially decrease groundwater supplies or interfere
substantially with groundwater recharge such that the project
may impede sustainable groundwater management of the
basin?
c) Substantially alter the existing drainage pattern of the site or
area, including through the alteration of the course of a stream
or river or through the addition of impervious surfaces, in a
manner which would:
Page 7
Issues
Potentially
Significant
Impact
Less Than
Significant
With
Mitigation
Incorporated
Less Than
Significant
Impact
No
Impact
i) result in a substantial erosion or siltation on- or off-site;
ii) substantially increase the rate or amount of surface
runoff in a manner which would result in flooding on- or
offsite;
iii) create or contribute runoff water which would exceed the
capacity of existing or planned stormwater drainage
systems or provide substantial additional sources of
polluted runoff; or
iv) impede or redirect flood flows?
d) In flood hazard, tsunami, or seiche zones, risk release of
pollutants due to project inundation?
e) Conflict with or obstruct implementation of a water quality
control plan or sustainable groundwater management plan?
a) Physically divide an established community?
b) Cause a significant environmental impact due to a conflict with
any land use plan, policy, or regulation adopted for the
purpose of avoiding or mitigating an environmental effect?
a) Result in the loss of availability of a known mineral resource
that would be a value to the region and the residents of the
state?
b) Result in the loss of availability of a locally important mineral
resource recovery site delineated on a local general plan,
specific plan or other land use plan?
a) Generation of a substantial temporary or permanent increase
in ambient noise levels in the vicinity of the project in excess
of standards established in the local general plan or noise
ordinance, or applicable standards of other agencies?
b) Generation of excessive groundborne vibration or
groundborne noise levels?
c) For a project located within the vicinity of a private airstrip or
an airport land use plan or, where such a plan has not been
adopted, within two miles of a public airport or public use
airport, would the project expose people residing or working in
the project area to excessive noise levels?
a) Induce substantial unplanned population growth in an area,
either directly (for example, by proposing new homes and
businesses) or indirectly (for example, through extension of
roads or other infrastructure)?
b) Displace substantial numbers of existing people or housing,
necessitating the construction of replacement housing
elsewhere?
a) Result in substantial adverse physical impacts associated with
the provision of new or physically altered governmental
facilities, need for new or physically altered governmental
facilities, the construction of which could cause significant
environmental impacts, in order to maintain acceptable
service ratios, response times, or other performance
objectives for any of the public services:
Page 8
Issues
Potentially
Significant
Impact
Less Than
Significant
With
Mitigation
Incorporated
Less Than
Significant
Impact
No
Impact
Fire protection?
Police protection?
Schools?
Parks?
Other public facilities?
a) Would the project increase the use of existing neighborhood
and regional parks or other recreational facilities such that
substantial physical deterioration of the facility would occur or
be accelerated?
b) Does the project include recreational facilities or require the
construction or expansion of recreational facilities which might
have an adverse physical effect on the environment?
a) Conflict with a program, plan, ordinance or policy addressing
the circulation system, including transit, roadway, bicycle and
pedestrian facilities?
b) Conflict or be inconsistent with CEQA Guidelines § 15064.3,
subdivision (b)?
c) Substantially increase hazards due to a geometric design
feature (e.g., sharp curves or dangerous intersections) or
incompatible uses (e.g., farm equipment)?
d) Result in inadequate emergency access?
a) Would the project cause a substantial adverse change in the
significance of a tribal cultural resource, defined in Public
Resources Code § 21074 as either a site, feature, place,
cultural landscape that is geographically defined in terms of
the size and scope of the landscape, sacred place, or object
with cultural value to a California Native American tribe, and
that is:
i) Listed or eligible for listing in the California Register of
Historical Resources, or in a local register of historical
resources as defined in Public Resources Code section
5020.1(k), or
ii) A resource determined by the lead agency, in its
discretion and supported by substantial evidence, to be
significant pursuant to criteria set forth in subdivision (c)
of Public Resources Code § 5024.1. In applying the
criteria set forth in subdivision (c) of Public Resource
Code § 5024.1, the lead agency shall consider the
significance of the resource to a California Native
American tribe.
a) Require or result in the relocation or construction of new or
expanded water, wastewater treatment or storm water
drainage, electric power, natural gas, or telecommunications
facilities, the construction or relocation of which could cause
significant environmental effects?
Page 9
Issues
Potentially
Significant
Impact
Less Than
Significant
With
Mitigation
Incorporated
Less Than
Significant
Impact
No
Impact
b) Have sufficient water supplies available to serve the project
and reasonably foreseeable future development during
normal, dry and multiple dry years?
c) Result in a determination by the waste water treatment
provider, which serves or may serve the project that it has
adequate capacity to serve the project’s projected demand in
addition to the provider’s existing commitments?
d) Generate solid waste in excess of state or local standards, or
in excess of the capacity of local infrastructure, or otherwise
impair the attainment of solid waste reduction goals?
e) Comply with federal, state, and local management and
reduction statutes and regulations related to solid waste?
a) Substantially impair an adopted emergency response plan or
emergency evacuation plan?
b) Due to slope, prevailing winds, and other factors, exacerbate
wildfire risks, and thereby expose project occupants to
pollutant concentrations from a wildfire or the uncontrolled
spread of a wildfire?
c) Require the installation or maintenance of associated
infrastructure (such as roads, fuel breaks, emergency water
sources, power lines or other utilities) that may exacerbate fire
risk or that may result in temporary or ongoing impacts to the
environment?
d) Expose people or structures to significant risks, including
downslope or downstream flooding or landslides, as a result of
runoff, post-fire slope instability, or drainage changes?
a) Does the project have the potential to substantially degrade
the quality of the environment, substantially reduce the habitat
of a fish or wildlife species, cause a fish or wildlife population
to drop below self-sustaining levels, threaten to eliminate a
plant or animal community, substantially reduce the number or
restrict the range of a rare or endangered plant or animal or
eliminate important examples of the major periods of
California history or prehistory?
b) Does the project have impacts that are individually limited, but
cumulatively considerable? (“Cumulatively considerable”
means that the incremental effects of a project are
considerable when viewed in connection with the effects of
past projects, the effects of other current projects, and the
effects of probable future projects.)
c) Does the project have environmental effects which will cause
substantial adverse effects on human beings, either directly or
indirectly?
Page 10
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