Fillable Sho rt Environmental Assessment Form (Monroe-Woodbury Central School District)

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Sho rt Environmental Assessment Form (Monroe-Woodbury Central School District)

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The Sho rt Environmental Assessment Form (Monroe-Woodbury Central School District) form is 3 pages long and contains:

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  • 17 check-boxes
  • 78 other fields

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Sho
rt Environmental Assessment Form
Part 1 - Project Information
Instructions for Completing
Part 1 - Projec
t 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 governmental 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, adjoining and near the proposed action.
9 Urban 9 Rural (non-agriculture) 9 Industrial 9 Commercial 9 Residential (suburban)
9 Forest 9 Agriculture 9 Aquatic 9 Other (specify): _________________________
9 Parkland
Page 1 of 3
Page 2 of 3
5. Is the proposed action,
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 service(s) available at or near the site of the proposed action?
c. Are any pedestrian accommodations or bicycle routes available on or near 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, describe method for providing wastewater treatment: ___
_____________________________
_______________________________________________________________________________________
NO YES
12. a. Does the site contain a structure that is listed on either the State or National Register of Historic
Places?
b. Is the proposed action located in an archeological sensitive area?
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, identify the wetland or waterbody and extent of alterations in square feet or acres: _______________
_______________________________________________________________________________________
_______________________________________________________________________________________
NO YES
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 plain?
NO YES
17. Will the proposed action create storm water discharge, either from point or non-point sources?
If Yes,
a. Will storm water discharges flow to adjacent properties? NO
YES
b. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?
If Yes, briefly describe: NO
YES
_______________________________________________________________________________________
_______________________________________________________________________________________
NO YES
18. Does the proposed action include construction or other activities that result in the impoundment of
water or other liquids (e.g. retention pond, waste lagoon, dam)?
If Yes, explain purpose and size: ____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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) for hazardous waste?
If Yes, describe: __________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
NO YES
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY
KNOWLEDGE
Applicant/sponsor name: ___________________________________________ Date: ___________________________
Signature: _______________________________________________________
Page 3
of 3
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Sho rt Environmental Assessment Form (Monroe-Woodbury Central School District)

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Completed 21 January 2021

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