SPECIAL ACTIVITY PERMITS • 1 Frank H. Ogawa Plaza, 1st Floor • Oakland, CA 94612
PRELIMINARY CHECKLIST FOR CANNABIS OPERATORS PURSUANT TO THE
CALIFORNIA ENVIRONMENTAL QUALITY ACT (CEQA)
APPLICANT NAME: _________________________________________________________
DBA: _____________________________________________________________________
APPLICANT CONTACT INFORMATION:
Phone No.: _______________________________________________________
E-mail: __________________________________________________________
Property Owner: _________________________________________________________________
Property Owner Mailing Address: ___________________________________________________
City/State:_____________________________________Zip: ______________________________
Phone No.: ______________________ E-mail: _______________________________________
I authorize the applicant indicated above to submit the application on my behalf.
Signature of Property Owner: _____________________________________________________
I. SITE INFORMATION
Project Address: __________________________________________________________
Project APN: ____________________________________________________________
CITY OF OAKLAND
Office of the City Administrator
PROPERTY OWNER AND APPLICANT INFORMATION
(Only complete if different from Applicant)
Original signatures or clear & legible copies are required.
click to sign
signature
click to edit
Project Overview and Description:
What is the approximate square footage of the building? _____________________________________
What is the total square footage of the entire project site? ____________________________________
Is the project new construction or rehabilitation of an existing facility?
New Construction Rehabilitation of an existing facility
If rehabilitation, is the number of units or square footage being changed? Yes No (Explain if yes)
What was the prior use of the property/premises?
If your application is approved, will there be multiple cannabis operators located at the property?
Yes No
If yes, how many and what is the approximate total square-footage for all cannabis operators?
Have you incorporated any measures into your project to mitigate or reduce potential environmental
impacts? Yes No Unknown
If so, list them here. (Examples include enrollment in clean energy programs, tree preservation plans,
creek restoration plans, and open space easements.)
Will the Project utilize a carbon dioxide generator as part of your cannabis facility? Yes No
If yes, will the carbon dioxide generator emit carbon dioxide into the air and at what levels? Please
explain and provide consultant report if necessary.
II. HISTORIC RESOURCES
Is the project site located within a historic district, or contain a historic building? Yes No
(Historic information can be obtained from the Planning & Zoning Division at (510) 238-6879)
a) If so, what is the OCHS (Oakland Cultural Heritage Survey) rating of the building?
___________________________________________________________________________
b) If so, is the building proposed for demolition or alteration?
___________________________________________________________________________
c) Is there a California Office of Historic Preservation DPR Form 523 with rating of 1 to 5?
__________________________________________________________________________
Note: Any modification to a historic building will require additional CEQA analysis and may not be eligible for a CEQA exemption.
III. HAZARDOUS MATERIALS
Is the subject property located on a State List of sites containing hazardous materials compiled
pursuant to Section 65962.5 of the Government Code? Yes No
(Cortese list, among others; more information can be obtained from California EPA at
https://www.dtsc.ca.gov/SiteCleanup/Cortese_List.cfm)
a) If so, has the site been remediated? ______________________________________________
b) Is there a “Closure Letter” from the appropriate regulatory Agency? ____________________
c) If not remediated, is there an approved Remedial Action Plan (RAP)? ___________________
d) If not, has a RAP been submitted? ______________________________________
IV. OTHER
Is the applicant aware of any other environmental conditions/impacts likely to require further CEQA or
National Environmental Policy Act (NEPA) review, such as:
i. Sensitive environments, e.g., creeks-wetlands, seismically active areas Yes No
ii. Peculiar or unique characteristics of the site, the project, or adjacent uses Yes No
Please explain:
I understand that review and approval of this preliminary CEQA checklist does not
constitute approval for any administrative review, conditional use permit, variance, or exception
from any other City regulations which are not specifically the subject of this application. I
understand further that I remain responsible for satisfying requirements of any private
restrictions or covenants appurtenant to the property. I understand that the Applicant and/or
Owner phone number listed above will be included on any public notice, if any, for the project.
I certify that I am the applicant and that the information submitted with this preliminary
CEQA checklist is true and accurate to the best of my knowledge and belief. I understand that
the City is not responsible for inaccuracies in information presented, and that inaccuracies may
result in the revocation of any permits as determined by the City. I further certify that I am the
owner or purchaser (or option holder) of the property involved in this application, or the lessee or
agent fully authorized by the owner to make this submission, as indicated by the owner’s signature
above.
I certify that statements, if any, made to me about the time it takes to review and process
this application are general. I am aware that the City has attempted to request everything
necessary for an accurate and complete CEQA review of my proposal; however, that after this
preliminary CEQA checklist and/or application has been submitted and reviewed by the City
Administrator’s Office, it may be necessary for the City to request additional information and/or
materials. I understand that any failure to submit the additional information and/or materials in
a timely manner may render the application inactive and that periods of inactivity do not count
towards statutory time limits applicable to the processing of this application.
Signature of Applicant: __________________________________________________
Date: ______________________________________
I HEREBY
CERTIFY
, UNDER PENALTY OF PERJURY, THAT ALL THE
INFORMATION PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT.
CEQA Review done by: ______________________________________________Date: ___________________________
Findings: Exempt Needs Additional Information
Notice of Exemption completed by: ___________________________________Date: _____________________________
FOR
OFFICE
USE
ONLY