TEPA Checklist Page 1
Title 19-01 of the Swinomish Tribal Code, Tribal Environmental Policy Act, (TEPA) requires that all actions
taken by or authorized under permits issued by the Tribe, unless exempt from such provisions, be
reviewed for potential environmental impacts. Accordingly, TEPA requires submission of an environmental
statement or checklist to provide information whereby the Tribe may identify, and where possible avoid,
the impacts of proposed actions and determine whether an Environmental Impact Statement (EIS) is
required. The checklist applies to all parts of a proposed action, even if planned over a period of time,
and should describe basic information about the proposal. A copy of the TEPA exemption list is available
from the Office of Planning and Community Development on request.
Fees: $100 for checklist review and publication of determination, due at time of application. An additional
$100 shall be paid if a site visit is required.
Applicant Address:
Owner Address:
Site Address/Project Location:
Parcel ID #: Acres:
Allotment Number (if applicable):
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Title of proposal (if applicable):
Nature and brief description of the proposal, including, but not limited to
proposed uses, size of the project and site, general design elements, and
other factors that give an accurate understanding of its scope and nature
(attach a project site plan and a vicinity map with project location
Describe the physical setting for the proposal, as well as the extent of the
land area affected by any environmental impacts; include any other
information needed to give an accurate understanding of the
environmental setting of the proposal.
Proposed timing or schedule (include phasing, if applicable)
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A. General description of the site:
Flat Steep slopes Rolling
Mountainous Hilly Other:
B. What are the steepest slopes on the site (approximate % slope)?
C. What general types of soils are found on the site (for example: clay,
sand, gravel, peat, muck)?
D. Are there surface indications or history of unstable soils in the
immediate vicinity? If so, describe.
E. Describe the purpose, type, and approximate quantities of any fill
proposed. Indicate source of fill, and indicate the excess disposal site.
F. Would the proposal result in the destruction, covering or modification
of any unique geologic or physical features?
G. Could wind or water erosion occur as a result of clearing,
construction, or use? If so, generally describe.
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H. Impervious surfaces:
1. Approximately what percent of the site is covered with impervious
surfaces prior to construction (for example: buildings or paved areas)?
2. How many square feet of impervious surface will be added by the
I. Would the proposal result in changes in deposition or erosion of a
beach, tidelands, or stream channel? If so, please describe.
J. Proposed measures to reduce or control erosion, if any.
Section 4 – AIR
A. What types of emissions to the air would result from the proposal
during construction and after the project is completed (for example,
dust, automobile, odors, industrial, wood smoke)? Describe and give
approximate quantities, if known.
B. Proposed measures to reduce or control emissions or other impacts to
air, if any.
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Section 5 – WATER
A. Surface water:
1. Are there any surface water bodies on or within 200 feet of the site,
including year-round or seasonal streams, saltwater, ponds, or
wetlands? If yes, describe type and provide names or locations of
such water bodies.
2. Will the project require any work over or in the described water
bodies? If yes, please describe and attach available plans.
3. Estimate the amount of fill or dredge material that would be placed
in or removed from tidelands, wetlands or stream channels and
indicate the area of the site that would be affected. Indicate the
source of fill material.
4. Will the proposal require surface water withdrawals or diversions?
Give general description, purpose, and approximate quantities, if
5. Does the proposal involve any discharge of waste into surface
waters? If so, describe the type and volume of discharge, and
anticipated change in water quality.
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B. Groundwater:
1. Will groundwater be withdrawn, or will water be discharged to
groundwater? Describe purpose, and approximate quantities.
2. Would the proposal result in an alteration of the direction or rate of
flow of groundwater either through direct withdrawals, or though
interceptions of an aquifer by cuts or excavations?
3. Describe waste material that will be discharged into the ground
from septic tanks or other sources. Describe the general size of the
system, the number of such systems, the number of houses to be
served (if applicable), or the number of animals or humans the
system(s) are expected to serve.
C. Water Runoff:
Describe the rate and amount of surface water runoff (including storm
water) resulting from changes in absorption rates of vegetation,
earth drainage patterns and the method of collection and disposal, if
any. Where will this water flow? If into surface waters, describe.
D. Proposed measures to reduce or control surface water, groundwater,
and runoff water impacts, if any.
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Section 6 – PLANTS
A. Check and list types of vegetation found on the site.
Deciduous trees:
Evergreen trees:
Wet soil plants:
Water plants:
B. What kinds and area of vegetation will be removed or altered? Is the
area proposed to be converted from forestry or native vegetation to
another use or cover type?
C. Proposed landscaping, use of native plants, or other measures to
preserve or enhance native vegetation or natural cover on the site.
Section 7 – ANIMALS
Check and list any birds and animals which have been observed on or near
the site or are known to be on or near the site.
Reptiles (snakes, lizards, etc.) Birds
Mammals (rodents, coyotes, deer, etc.) Fish
Amphibians (frogs, toads, etc.) Other:
B. List any threatened or endangered species (plant or animal) known to
be on or near the site.
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C. Will the proposal result in an introduction of new species into the
area, or result in a barrier to the migration or movement of fish or
D. Proposed measures to preserve or enhance fish or wildlife, if any.
A. What kinds of energy (electric, natural gas, oil, wood stove, solar) will
be used to meet the completed project's energy needs? Describe
whether it will be used for heating, manufacturing, etc..
B. Would the proposal result in a measurable increase in the rate of use
of any natural resources or in a measurable depletion of any non-
renewable resource?
C. Would the proposal require the development of new sources of
D. What kinds of energy conservation features are included in the plans
of this proposal? List other proposed measures to reduce or control
energy impacts, if any.
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A. Would the proposal involve any environmental health hazards,
including exposure to toxic chemicals, risk of fire and explosion, spill
(i.e. oil, gasoline, pesticides, and other chemicals), or hazardous
waste, that could occur in the event of an accident or upset condition?
If so, describe:
B. Proposed measures to reduce or control environmental health
hazards, if any:
Section 10 – NOISE
A. What types and levels of noise would be created by or associated
with the project on a short-term or a long-term basis (for example:
traffic, construction, operation, other)? Indicate what hours noise
would come from the site.
B. Proposed measures to reduce or control noise impacts, if any.
Section 11 – LIGHT AND GLARE
A. What type of light or glare will the proposal produce? What time of
day would it mainly occur?
B. Could light or glare from the finished project be a safety hazard or
interfere with views?
C. Proposed measures to reduce or control light and glare impacts, if
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Section 12 – LAND USE
A. What is the current use of the site and adjacent properties?
B. Describe any structures on the site.
C. Will any structures be demolished? If so, what?
D. What is the current zoning classification of the site?
E. Will the proposal result in the alteration of the present or planned use
of an area?
F. Has any part of the site been classified as a sensitive area? If so,
G. Proposed measures to ensure the proposal is compatible with existing
and projected land uses and plans, if any:
Section 13 – UTILITIES
A. List utilities currently located on the site (for example: electricity,
natural gas, water, refuse service, telephone, sanitary sewer, septic
system, etc.).
B. Describe any new or expanded utilities proposed for the project.
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Section 14 – AESTHETICS
A. What is the tallest height of any proposed structure(s), not including
antennas? What is the principal exterior building material(s)
B. Will views in the immediate vicinity would be altered or obstructed?
C. Proposed measures to reduce or control aesthetic impacts, if any.
Section 15 – RECREATION
A. What designated and informal recreational opportunities are in the
immediate vicinity?
B. Would the proposed project displace any existing recreational uses?
If so, describe.
C. Proposed measures to reduce or control impacts on recreation,
including recreation opportunities to be provided by the project, if
A. Describe any landmarks or evidence of historic, archaeological,
scientific, or cultural importance known to be on or adjacent to the site.
B. Proposed measures to reduce or control impacts, if any.
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Section 17 – Population
A. Will the proposal alter the location, distribution, density, or growth
rate of the human population of an area?
B. Approximately how many people would reside or work in the
completed project?
C. Approximately how many people could be displaced by the project?
D. Proposed measures to avoid or reduce displacement impacts, if any?
Section 18 – Housing
A. Approximately how many units would be provided, if any? Indicate
whether high, middle, or low-income housing.
B. Approximately how many units, if any, would be eliminated? Indicate
whether high, middle, or low-income housing.
C. Proposed measures to reduce or control housing impacts, if any.
Section 19 – Transportation
A. Identify public streets and highways serving the site, and describe
access to the existing street system. Show on site plans also.
B. Is the site currently served by public transit? If not, what is the
approximate distance to the nearest transit stop?
The following sections (17 – 20) are required for projects other
than single-family housing (attach additional sheets as necessary).
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C. How many parking spaces would the completed project have? How
many would the project eliminate?
D. Will the proposal require any new roads or streets, or improvements
to existing roads or streets, not including driveways? If so, generally
describe (indicate public or private).
E. How many vehicular trips per day would be generated by the
completed project? If known, indicate when the peak volumes would
F. Will the proposal result in increase in traffic hazards to motor vehicles,
bicyclists or pedestrians?
G. Proposed measures to reduce or control transportation impacts, if
Section 20 – Public Services
A. Would the project result in an increased need for public services (for
example: fire protection, police protection, health care, schools,
other)? If so, generally describe.
B. Proposed measures to reduce or control direct impacts on public
services, if any.
I, the undersigned, state that to the best of my knowledge that above information is true and complete. I
understand that the Swinomish Office of Planning and Community Development is relying on them to make
its decision. It is understood that the Tribe may withdraw any declaration of non-significance that it might
issue in reliance upon this checklist should there be any willful misrepresentation or willful lack of full
disclosure on my part.
Signature:_______________________________ Date:_______________