Fillable Suffolk County Short Environmental Assessment Form (Suffolk County Government)

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Suffolk County Short Environmental Assessment Form (Suffolk County Government)

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File type: PDF

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BROWSE SUFFOLK COUNTY GOVERNMENT (NY) FORMS

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Rev. 05/16/06 Page 1
PROJECT I.D. NUMBER
SEQR
SUFFOLK COUNTY DEPARTMENT OF HEALTH SERVICES
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I-PROJECT INFORMATION
1. APPLICANT / SPONSOR
2. PROJECT NAME
3. PROJECT LOCATION:
County
Suffolk
4. PRECISE LOCATION (SCTM, and Street address or road intersections, prominent landmarks, etc.)
5. IS PROPOSED ACTION:
New
Expansion
Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
7. AMOUNT OF LAND AFFECTED:
Initially
acres
Ultimately
acres
8. WILL PROPOSED ACTION COMPLY WITH EXISTING ZONING OR OTHER EXISTING LAND USE RESTRICTIONS?
Yes
No
If No, describe briefly
9. WHAT IS PRESENT LAND USE IN VICINITY OF PROJECT?
Residential
Industrial
Commercial
Agriculture
Park/Forest/Open space
Other
Describe:
10. DOES ACTION INVOLVE A PERMIT APPROVAL, OR FUNDING, NOW OR ULTIMATELY FROM ANY OTHER GOVERNMENTAL AGENCY
(FEDERAL, STATE OR LOCAL)?
Yes
No
If Yes, list agency(s) name and permit/approval
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL
Yes
No
If Yes, list agency name and permit/approval
12. AS A RESULT OF PROPOSED ACTION WILL EXISTING PERMIT/APPROVAL REQUIRE MODIFICATION?
Yes
No
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE
Applicant / Sponsor Name
Signature
Date
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Suffolk County Short Environmental Assessment Form (Suffolk County Government)

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Completed 6 August 2020

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