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Short Environmental Assessment Form
Part 1 - Project Information
Instructions for Completing
Part 1 Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the
application for approval or funding, are subject to public review, and may be subject to further verification. Complete Part 1 based on
information currently available. If additional research or investigation would be needed to fully respond to any item, please answer as
thoroughly as possible based on current information.
Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the
lead agency; attach additional pages as necessary to supplement any item.
Part 1 Project and Sponsor Information
Name of Action or Project:
Project Location (describe, and attach a location map):
Brief Description of Proposed Action:
Name of Applicant or Sponsor:
Telephone:
E-Mail:
Address:
City/PO:
State:
Zip Code:
1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance,
administrative rule, or regulation?
If Yes, attach a narrative description of the intent of the proposed action and the environmental resources that
may be affected in the municipality and proceed to Part 2. If no, continue to question 2.
NO YES
2. Does the proposed action require a permit, approval or funding from any other government Agency?
If Yes, list agency(s) name and permit or approval:
NO
YES
3. a. Total acreage of the site of the proposed action? __________ acres
b. Total acreage to be physically disturbed? __________ acres
c. Total acreage (project site and any contiguous properties) owned
or controlled by the applicant or project sponsor? __________ acres
4. Check all land uses that occur on, are adjoining or near the proposed action:
5. Urban Rural (non-agriculture) Industrial
Commercial Residential (suburban)
Aquatic Other(Specify):
Forest Agriculture
Parkland
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a. A permitted use under the zoning regulations?
b. Consistent
with the adopted comprehensive plan?
NO
YES
N/A
6. Is the proposed action consistent with the predominant character of the existing built or natural landscape?
NO YES
7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area?
If Yes, identify: ________________________________________________________________________________
NO YES
8. a. Will the proposed action result in a substantial increase in traffic above present levels?
b. Are public transportation services available at or near the site of the proposed action?
c. Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed
action?
NO YES
9. Does the proposed action meet or exceed the state energy code requirements?
If the proposed action will exceed requirements, describe design features and technologies:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
NO YES
10. Will the proposed action connect to an existing public/private water supply?
If No, describe method for providing potable water: _________________________________________
_____________________________________________________________________________________________
NO
YES
11. Will the proposed action connect to existing wastewater utilities?
If No, descri
be method for providing wastewater treatment: ______________________________________
____________________________
_________________________________________________________________
NO YES
archaeological sites on the NY State Historic Preservation Office (SHPO) archaeological site inventory?
NO
YES
13. a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, contain
wetlands or other waterbodies regulated by a federal, state or local agency?
b. Would the proposed action physically alter, or encroach into, any existing wetland or waterbody?
If Yes, iden
tify the wetland or waterbody and extent of alterations in square feet or acres: _____________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
NO
YES
12. a. Does the project site contain, or is it substantially contiguous to, a building, archaeological site, or district
which is listed on the National or State Register of Historic Places, or that has been determined by the
Commissioner of the NYS Office of Parks, Recreation and Historic Preservation to be eligible for listing on the
State Register of Historic Places?
b. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for
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14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply:
Shoreline Forest Agricultural/grasslands Early mid-successional
Wetland Urban Suburban
15. Does the site of the proposed action contain any species of animal, or associated habitats, listed by the State or
Federal government as threatened or endangered?
NO
YES
16. Is the project site located in the 100-year flood plan?
NO
YES
17. Will the proposed action create storm water discharge, either from point or non-point sources?
If Yes,
a. Will storm wa
ter discharges flow to adjacent properties?
b. Will storm wa
ter discharges be directed to established conveyance systems (runoff and storm drains)?
If Yes, briefly describe:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
NO
YES
18. Does the proposed a
ction include construction or other activities that would result in the impoundment of water
or
other liquids (e.g., retention pond, waste lagoon, dam)?
If Yes, explain the purpose and size of the impoundment:______________________________________________
____________________________________________________________________________________________
_
NO
YES
19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste
management facility?
If Yes, describe: _______________________________________________________________________________
_____________________________________________________________________________________________
NO
YES
20.Has the site of the proposed action or an adjoining property been the subject of remediation (
ongoing or
completed)
fo
r hazardous waste?
If Yes, describe: _______________________________________________________________________________
_____________________________________________________________________________________________
NO
YES
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF
MY KNOWLEDGE
Date: _____________________
Applicant/sponsor/name: ____________________________________________________ ____________________
______
Signature: _____________________________________________________Title:__________________________________
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Agency Use Only [If applicable]
Project:
Date:
Short Environmental Assessment Form
Part 2 - Impact Assessment
Part 2 is to be completed by the Lead Agency.
Answer all of the following questions in Part 2 using the information contained in Part 1 and other materials submitted by
the project sponsor or otherwise available to the
reviewer. When answering the questions the reviewer should be guided by
the concept “Have my responses been reasonable considering the scale and context of the proposed action?”
No, or
small
impact
may
occur
Moderate
to large
impact
may
occur
1. Will the proposed action create a material conflict with an adopted land use plan or zoning
regulations?
2. Will the proposed action result in a change in the use or intensity of use of land?
3. Will the proposed action impair the character or quality of the existing community?
4. Will the proposed action have an impact on the environmental characteristics that caused the
establishment of a Critical Environmental Area (CEA)?
5. Will the proposed action result in an adverse change in the existing level of traffic or
affect existing infrastructure for mass transit, biking or walkway?
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate
reasonably available energy conservation or renewable energy opportunities?
7. Will the proposed action impact existing:
a. public / private water supplies?
b. public / private wastewater treatment utilities?
8. Will the proposed action impair the character or quality of important historic, archaeological,
architectural or aesthetic resources?
9. Will the proposed action result in an adverse change to natural resources (e.g., wetlands,
waterbodies, groundwater, air quality, flora and fauna)?
10. Will the proposed action result in an increase in the potential for erosion, flooding or drainage
problems?
11. Will the proposed action create a hazard to environmental resources or human health?
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For every question in Part 2 that was answered “moderate to large impact may occur”, or if there is a need to explain why a
particular element of the proposed action may or will not result in a significant adverse environmental impact, please
complete Part 3. Part 3 should, in sufficient detail, identify the impact, including any measures or design elements that
have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency
determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting,
probability of occurring, duration, irreversibility, geographic scope and magnitude. Also consider the potential for short-
term, long-term and cumulative impacts.
Check this box if you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action may result in one or more potentially large or significant adverse impacts and an
environmental impact statement is required.
Check this box if you have determined, based on the information and analysis above, and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
_________________________________________________ _______________________________________________
Name of Lead Agency Date
_________________________________________________ _______________________________________________
Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer
_________________________________________________ _______________________________________________
Signature of Responsible Officer in Lead Agency Signature of Preparer (if different from Responsible Officer)
Short Environmental Assessment Form
Part 3 Determination of Significance
Agency Use Only [If applicable]
Project:
Date:
PRINT FORM
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