Germantown: SEAF PART 1

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
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Does the proposed action only involve the legislative adoption of a plan, local law, ordinance,administrative rule, or regulation?

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

NOYES
If Yes, list agency(s) name and permit or approval:

	Acres
a. Total acreage of the site of the proposed action?
b. Total acreage to be physically disturbed?
c. Total acreage (project site and any contiguous properties) owned or controlled by the applicant or project sponsor?

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

UrbanRural (non-agriculture)IndustrialCommercial Residential (suburban)ForestAgricultureAquaticParklandOther(Specify)

5. Is the proposed action,

	NO	YES	N/A
a. A permitted use under the zoning regulations?
b. Consistent with the adopted comprehensive plan?

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

NOYES
7. Is the proposed action consistent with the predominant character of the existing built or natural landscape?

NOYES
If Yes, identify

	NO	YES
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?

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

NOYES
If the proposed action will exceed requirements, describe design features and technologies:
10. Will the proposed action connect to an existing public/private water supply?

NOYES
If No, describe method for providing potable water
11. Will the proposed action connect to existing wastewater utilities?

NOYES
If No, describe method for providing wastewater treatment

12.

	NO	YES
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 reservation 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 archaeological sites on the NY State Historic Preservation Office (SHPO) archaeological site inventory?

13.

	NO	YES
a. Does any portion of the site of the proposed action, or lands adjoining the proposed action, containwetlands 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

Short Environmental Assessment Form

Part 1 - Project and Sponsor Information