Form Center

Short Environmental Assessment Form

2. Short Environmental Assessment Form
   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 to supplement any item.

   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 to supplement any item.

4. Part 1: Project and Sponsor Information

6. Name of Action or Project:*

8. Project Location (describe, and attach a location map):*

10. Attach a location map

12. Brief Description of Proposed Action:*

14. First Name

15. Last Name

17. Address

19. City

20. State

21. Zip Code

23. Phone Number

24. Fax Number

26. Email Address

28. 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.

    1. Yes
    2. No

30. If you answered "Yes" to the above question, please attached a narrative description of the intent of the proposed action as described above.

32. 2. Does the proposed action require a permit, approval or funding from any other government agency?

    1. Yes
    2. No

34. If yes, please list agency(s) name and permit approval

36. 3. a.Total acreage of the site of the proposed action?

38. 3. b. Total acreage to be physically disturbed?

40. 3. c. Total acreage (project site and any contiguous properties) owned or controlled by the applicant or project sponsor?

42. Check all land uses that occur on, are adjoining or near the proposed action:

    1. Urban
    2. Forest
    3. Parkland
    4. Industrial
    5. Aquatic
    6. Commercial
    7. Residential (suburban)
    8. Other

44. If you selected "other", please specify:

46. 5. a. Is the proposed action, a permitted use under the zoning regulations?

    1. Yes
    2. No
    3. Not Applicable

48. 5. b. Is the proposed action, consistent with the adopted comprehensive plan?

    1. Yes
    2. No
    3. Not Applicable

50. 6. Is the proposed action consistent with the predominant character of the existing built of natural landscape?

    1. Yes
    2. No

52. 7. Is the site of the proposed action located in, or does it adjoin, a state listed Critical Environmental Area?

    1. Yes
    2. No

54. If yes, please identify:

56. 8. a. Will the proposed action result in a substantial increase in traffic above present levels?

    1. Yes
    2. No

58. 8. b. Are public transportation services available at or near the site of the proposed action?

    1. Yes
    2. No

60. 8. c. Are any pedestrian accommodations or bicycle routes available on or near the site of the proposed action?

    1. Yes
    2. No

62. 9. Does the proposed action meet or exceed the state energy code requirements?

    1. Yes
    2. No

64. If the proposed action will exceed requirements, describe design features and technologies:

66. 10. Will the proposed action connect to an existing public/private water supply?

    1. Yes
    2. No

68. If no, describe method for potable water:

70. 11. Will the proposed action connect to existing wastewater facilities?

    1. Yes
    2. No

72. If no, describe method for providing wastewater treatment:

74. 12. a. Does the project site contain, or is 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?

    1. Yes
    2. No

76. 12. b. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for archaeological sites on the NY State Historic Preservation Office (SHPO) archaeological site inventory?

    1. Yes
    2. No

78. 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.

    1. Yes
    2. No

80. 13. b. Would the proposed action physically alter, or encroach into, any existing wetland, or waterbody?

    1. Yes
    2. No

82. If yes, identify the wetland or waterbody and extent of alterations in square feet or acres:

84. 14. Identify the typical habitat types that occur on, or are likely to be found on the project site. Check all that apply:

    1. Shoreline
    2. Wetland
    3. Forest
    4. Urban
    5. Agricultural/grasslands
    6. Suburban
    7. Early mid-successional

86. 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?

    1. Yes
    2. No

88. 16. Is the project site locate din the 100-year flood plan?

    1. Yes
    2. No

90. 17. Will the proposed action create storm water discharge, either from point of non-point sources?

    1. Yes
    2. No

92. Will storm water discharges flow to adjacent properties?

    1. Yes
    2. No

94. Will storm water discharges be directed to established conveyance systems (runoff and storm drains)?

    1. Yes
    2. No

96. If yes, describe briefly:

98. 18. Does the proposed action include construction or other activities that would result in the impoundment of water or other liquids (eg. retention pond, waste lagoon, dam)?

    1. Yes
    2. No

100. If yes, describe:

102. 19. Has the site of the proposed action or an adjoining property been the location of an active or closed solid waste management facility?

     1. Yes
     2. No

104. If yes, describe:

106. 20. Has the site of the proposed action or an adjoining property been the subject of remediation (ongoing or completed) for hazardous waste?

     1. Yes
     2. No

108. If yes, describe:

112. I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

114. Applicant/sponsor/name:

115. Date

117. Signature

118. Title

Leave This Blank:


120. 1. Receive an email copy of this form.
121. Email address

     This field is not part of the form submission.

122. Submit Submit and Print

* indicates a required field