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9 Yes 9 No
• Do existing sewer lines serve the project site?
a line extension within an existing district be necessary to serve the project?
9 Yes 9 No
• Describe extensions or capacity expansions proposed to serve this project: ____________________________________
iv. Will a new wastewater (sewage) treatment district be formed to serve the project site? 9 Yes 9 No
• Applicant/sponsor for new district: ____________________________________________________________________
• Date application submitted or anticipated: _______________________________________________________________
• What is the receiving water for the wastewater discharge? __________________________________________________
v. If public facilities will not be used, describe plans to provide wastewater treatment for the project, including specifying proposed
receiving water (name and classification if surface discharge or describe subsurface disposal plans):
vi. Describe any plans or designs to capture, recycle or reuse liquid waste: _______________________________________________
e. Will the proposed action disturb more than one acre and create stormwater runoff, either from new point 9 Yes 9 No
sources (i.e. ditches, pipes, swales, curbs, gutters or other concentrated flows of stormwater) or non-point
source (i.e. sheet flow) during construction or post construction?
How much impervious surface will the project create in relation to total size of project parcel?
_____ Square feet or _____ acres (impervious surface)
_____ Square feet or _____ acres (parcel size)
Describe types of new point sources. __________________________________________________________________________
iii. Where will the stormwater runoff be directed (i.e. on-site stormwater management facility/structures, adjacent properties,
groundwater, on-site surface water or off-site surface waters)?
• If to surface waters, identify receiving water bodies or wetlands: ______________________________________
• Will stormwater runoff flow to adjacent properties? 9 Yes 9 No
iv. Does the proposed plan minimize impervious surfaces, use pervious materials or collect and re-use stormwater?
9 Yes 9 No
f. Does the proposed action include, or will it use on-site, one or more sources of air emissions, including fuel 9 Yes 9 No
combustion, waste incineration, or other processes or operations?
If Yes, identify:
i. Mobile sources during project operations (e.g., heavy equipment, fleet or delivery vehicles)
ii. Stationary sources during construction (e.g., power generation, structural heating, batch plant, crushers)
iii. Stationary sources during operations (e.g., process emissions, large boilers, electric generation)
g. Will any air emission sources named in D.2.f (above), require a NY State Air Registration, Air Facility Permit, 9 Yes 9 No
or Federal Clean Air Act Title IV or Title V Permit?
i. Is the project site located in an Air quality non-attainment area? (Area routinely or periodically fails to meet 9 Yes 9 No
ambient air quality standards for all or some parts of the year)
ii. In addition to emissions as calculated in the application, the project will generate:
___________Tons/year (short tons) of Carbon Dioxide (CO
___________Tons/year (short tons) of Nitrous Oxide (N
___________Tons/year (short tons) of Perfluorocarbons (PFCs)
___________Tons/year (short tons) of Sulfur Hexafluoride (SF
___________Tons/year (short tons) of Carbon Dioxide equivalent of Hydroflourocarbons (HFCs)
__Tons/year (short tons) of Hazardous Air Pollutants (HAPs)