HomeMy WebLinkAboutTR-4720Albert J. Krupski, President
John Hohapfel, Vice President
Jim King
Martin H. Garrell
Peter Wenczel
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLI%
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892.
Fax (516) 765-1823
Office Use Only
Cgastal Erosion Permit Appllcati~on'-~%
Grandfather Pemit APplication
~etland Ps.mit Application
--~aiver / ~en~ent / Cha~ge s
}~e~vea Application: ~$~ ~;: ~
x Received Fee:$ ~
Completed Application ~
Incomplete
SEQ~ Classification:
~e I__.~e II Unlisted
Coordination: (date sent)
CAC Referral Sent: ~-to~
Date of Inspection: ~7
Receipt of CAC Report:
'Lead Agency Determination:__
Technical Review:
Public Hearing Held:
Resolution:
N~ne of Applicant Hay Harbor CLub
Address Bell Hill Avenue
'. Phone Number: ( 516 ) 788-7323 '
Suffolk County Tax Map Number: 1000 - 009-3-1, 3
Property Location: The Hay Harbor CLub is located on Bell Hill Avenue
just west of the intersection with Fox Avenue.
(provide LILCO Pole %, distance to cross streets, and location)
AGENT: ' Docko, Inc.-, Keith B. Neilson, P.E. ~------'
(If applicable)
Address: PO Box 421, 18 Stafford STreet, Mystic, CT 06355
Phone: 860-572-8939
FAX~: 860-572-7569
_ ard of Trustees Applicatic.
GENERAL DATA
Land Area ( in square feet ): Not applicable
Area Zoning: Generally R~sidential surrounding Hay Harbor.
previous use of property:
Intended use of property:
Hay Harbor Club
The property use will remain as is.
Prior permits/approvals for site improvements:
Agency Date
Tidal Wetlands Permit
1992 (Dock Reconstruction-Hurrmcane Bob)
No prior permits/approvals for site improvements.
Has any permit/approval ever been revoked or suspended by a
goVernmental agency?
xx No Yes
If yes, provide explanation:
Project Description (use attachments if necessary): ·
The diving area at the swimming dock has gradualy filled in with sand,
especially from gales from the west and northwest, and needs to be dredged
3 feetmore or less,.' ~ w' t~ansp~T~b~ge~ove~~
~D~ock-~H~rbo~nS~off=to~ded,--~~ck~-re-
ard of Trustees Applicati~
County of Suffolk
State of New York
Richard Duggan
BEING DULY SWORN
DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE
DESCRIBED PERMIT(S) AND THAT ALL STATEMENTS CONTAINED HEREIN ARE
TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF~ AND THAT ALL
WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION
AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES.
THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE TOWN
TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS
ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN
COMPLETING THIS APPLICATION, I HEREBY AUTHORIZE THE TRUSTEES,
THEIR AGENT(S) OR REPRESENTATIVES(S), TO ENTER ONTO MY PROPERTY
TO INSPECT THE PREMISES IN CONJUNCTION WITH REVIEW OF THIS
APPLICATION.
S ~atu~f/
Notar~ Public
3
. ard of Trustees Applicati~
AUTHORIZATION
(where the applicant is not the owner)
I, Richard Duggan, Manager
(print owner of property)
residing at Hay Harbor Club
(mailing address)
Fishers Island, NY
Keith B. Neilson, P.E.
do hereby authorize Docko, Inc.
(Agent)
to apply for pezmit(s) from the
Southold Board of Town Trustees on my behalf.
Project:
Waterway:
Location:
Applicant:
Date:
102
LOCATION MAP
"Maintenance Dredging"
Hay Harbor
Fishers Island, Town of Southold
Suffolk County, New York
Hay Harbor Club
February 28, 1997
37
Silver Eel Cove
U S COAST GUARD *q
U
Earbor
h
Field
.... .) / ·
0
/ S LA/kl D
I
/WOT~ ..
PROJECT: ~/~T~
LOCATION: ~.~
WATERWAY: t~Y
DATE: ~y
APPLICANT: ~y
DOCKO, INC.
P.O. BOX 42 t, MYSTIC, CT 06355
203 572 8939 F~ 572 7569
× ./?~
PROJECT:
LOCATION:
WATERWAY: H~ /-/~,,~o,,~-
DATE: ~b'~,~v ~.,, t~
APPLICANT: t--¢,~," ~"/A,~-.,,,,~P.... ¢__~C,.I,~
AGENT - SHEET '/
DOCKO, INC.
KEITH B. NEILSON, P.E.
P.O. BOX 421, MYSTIC, CT 06355
203 572 8939 FAX 572 7569
oF
lei'Ay
LOCATION: ,,~- A,,S/-/~_~ ,~-"S
WATERWAY: ,A/A, ~,'
DATE: ,~(~-U~-~ Y' ,,~,~ ~/,~r'~
APPLICANT: H,~y'
AGENT SHEET
DOCKO, INC.
KEITH B. NEILSON. P.E.
P.O. BOX .421. IVlYSTIC. CT 06355
203 572 8939 FAX 572 7569
Albert J. Krupski, President
John Holzapfel, Vice President
Jim King
Martin H. Garrell
Peter Wenczel
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
BOARD OF TRUSTEES: TOWN OF SOUTHOLD
In the Matter of the Application
of
COUNTY OF SUFFOLK)
STATE OF NEW YORK)
AFFIDAVIT OF POSTING
Z,/~t:~t/ ~ ~-,,~ , residing at /~ //~4
bein~ duly sworn, aepose and say:
~at on the /f~day of~cff, 199~, I personally posted the
property ~o~ as ~ ~¢ ~& ~ ~
by placing the Board of ~rustees official poster where it can
easily be seen, ~d that I have checked to be sure the poster
has remained in place for seven days prior to the date of ~e
public hearing. (date of hearing noted thereon to be
Dated:
Sworn 'to before me this .
Notafx!~ Public ~
~signa~e ) ~/
Board Of Southold Town Trustees
SOUTHOLD, NEW YORK
PERMIT NO.. '~_~ ....... DATE: ..APrtl.
ISSUED TO ....... g~., ~.B. rt2p..r,.....~.,'.~
Pursuant to the provisions of Chapter 615 of the Laws of
the State of New York, 1893; and Chapter 404 of the Laws of the
State of New York 1952; and the Southold Town Ordinance en
titled "REGULATING AND THE PLACING OF OBSTRUCTIONS '
IN AND ON TOWN WATERS AND PUBLIC LANDS and the
REMOVAL OF SAND, GRAVEL OR OTHER MATERIALS FROM
LANDS UNDER TOWN WATERS;" and in accordance with the
Resolution of The Board adopted at a meeting held on
19....9.7._, and in consideration of the sum of $_....~=.5.g.~..g0 ..... paid by
..... I)~c~.;~,....~,...(~r~....b~f...~f...k!.~T...H.~g~....(2~g:~. ..............................
of .................................................................................... N. Y. and subject to 'the
Terms and COnditions listed on the reverse side hereof,
of Southold Town TrUstees authorizes and permits the following:
maintenance dredge +/-3' in a 15' X 15' area off existing dock
used for diving and swimming. Spbil will be de-watered and
removed to an approved upland site. Permit will run with DEC
permit, to year 2002.
all in accordance with the detailed specifications as ~presented in
the orlg~nating application.
IN WITNESS WHEREOF, The said Board of Trustees here-
: by causes its Corporate Seal to be affixed, and these presents to
be subscribed by a majority of the said Board as of this date~
Trustee
Albert J. Kmpski, President
John Holzapfel. Vice President
Jim King
Martin H. Gar, ell
Peter Wenczel
BOARD OF TOWN TRUSTEES
TOWN OF SOUTHOLD
Town Hall
53095 Main Road
P.O. Box 1179
Southold, New York 11971
Telephone (516) 765-1892
Fax (516) 765-1823
April 3, 1997
Docko, Inc.
P.O. Box 421
18 Stafford Street
Mystic, CT 06355
Re: Hay Habor Club
SCTM g~ 9-3-1,3
Dear Mr. Neilson:
The following action was taken b~ the Board of Town Trustees
during its regular meeting held on~a~ck 26, 1997 reg_ard~ng tke
above matter:
WHEREAS, Docko, Inc. on behalf of HAY HARBOR CLUB applied to the
Southold Town Trustees for a permit und~r the provisions of the
Wetland Ordinance of the Town of Southotd, application dated
March 5, 1997, and,
WHEREAS, said application was referred to the Southold Tow~
Conservation Advisor~ Council for their findings and.
recommendations, and
WHF. REAS, a Public Heazing was held by the Town Trustees witk
respect to s~d applfcation on March 26, i997, at which time all
interested pe~sonswere give~ a~oppo~tunit-f to be h'eard, and,
WHEREAS, the Board members have personally viewe&and a~e
familiar with the premises i~guestion and t~e surr~,nd~u~ area,
and,
WHEREAS, the Board has conside~e~ all th~ testimony and.
documentation submitte~concernin~ this application, and,
WHEREAS, the structure complies wi~h the standa~ set fo~t~ i~
Chapter 37-18 of the Sou~hold Town Code,
WHEREAS, the Board has determined that th~. pro3ect as proposed
will not affect the health, safet~ and general welfar:e of the
people of the town,
NOW THEREFORE BE IT,
RESOLVED, that the Board of Trustees grant a Wetland Permit to
maintenance dredge +/- 3' in a 15' X 15' area off exist%~g dock
used for diving an~ sw~,m~ng. Spoil wilt be de-watere~ an~ then
removed to an approved upla~E1 site. Permit will run with DEC
permit, to year 20O2, and,
BE IT FURTHE~ R~-~OLVED that this deteI~tion sh~ul~ not he
consideze~i a dete~m'%nation mad~ for a~y o~h~-r ~epartment on
Agency which, may also have an application pena%ng for the sam~
or similar project.
~X~K ~$DrX~XX~~IX~X~ ~aK~X~K~K~X
~X~X$~X Fees must he paid, if applicable, and permit
issued within six months of the date of this notificatinn.
Two inspections are requized and the T~-~tees are to he notified
upon completion of s~d project.
FEES.: None.
Very truly yours,
Albert J. Krupski, Jr.
President, Board of Trustees
AJK/jmd
Docko, Inc.
P.O. Box 421 Mystic, CT 06355 (860) 572-8939 Fax: (860) 572-7569
Mr, Albert J. Krupski,
Southold Board of Trustees
P O Box 1179
Southold, NY 11971
1997
Re: Hay Harbor Dredge Permit
Dear Mr. Krupski:
We understand that the Board of Trustees will recommend a full permit for the dredging
of the diving area at the Hay Harbor Club on Fishers Island. In accordance with that decision
we submit, herewith, a check in the amount of $110 which will bring the total permit application
fee to $150, as required for a full permit. We also understand, from Ms. Jill Dougherty, that our
application documents are complete and appropriate for the requested work and are adequate for
a full permit application.
We also understand from Ms. Dougherty that the upland disposal site, beach
replenishment near the south dock, is not acceptable to the DEC and will work with Mr.
Hamilton of the Marine Habitat Protection division to £md a more suitable upland disposal site.
In the event that it is not usable for beach replenishment on the site it may be used in other
Fishers Island construction site projects as routine backfill.
I trust that this supplemental application fee payment will enable the board to approve this
project as ,'equeste& Yo~ ~ssistance and tLm._e!L~ess in this project has been greatly appreciated.
Please let me know if the need for further information or discussion arises.
Very truly yours,
DOCKO, INC.
Keith B. Neilson, P.E.
K-BN:cmc
:Enclosure
cc: Hay Harbor Club: Duggan
NYS DEC: Hamilton
File: 90-07-190 HAY-HBR.KRU
Telephone
(516) 765-1501
Town Hall. 53095 Main l~oad
P.O. Box 1179
Southold, New York 11971
SOUTIIOLD TOWN
CONSERVATION ADVISORY COUNCIL
The following recommendation was made at the March 2L~. 1997 meeting of the
Southold Town Conservation Advisory Council:
No. 1L~26
HAY HARBOR CLUB 9-3-1. 3 to maintenance dredge 3' +/- in a 15' x 15'
area off existing dock used for diving and swimming. Spoil to be dewatered
and removed to an approved upland site. Request that permit run with DEC
(5 year).
Bell Hill Avenue, Fishers Island
The Council did not make an inspection therefore it has no recommendation.
DoCko, Inc.
P.O. Box 421, Mystic, CT 06355 (860) 572-8939 Fax: (860) 572-7569
February 28,
Mr. Albert J. Krupsld, President
Southold Board of Trustees
P O Box 1179
Southold, NY 11971
Dear Mr. Kmpski:
Re:
Hay Harbor Club
Maintenance Dredging
On behalf of the Hay Harbor Club, we request a Tidal Wetlands Permit waiver for
maintenance dredging of their open water diving area in Hay Harbor. We enclose herewith the
following in support of this application:
- Two prints each of plans titled:
"Maintenance Dredging"
Hay Harbor
Fishers Island, Town of Southold
Suffolk County, New York
Hay Harbor Club
February 28, 1997
Project:
Waterway:
Location:
Applicant:
Date:
- Four copies of the Town of Southold application form, Tax Assessor's map
and location map.
- Check in the mount of $40 payable to the Town of Southold.
I trust that you will £md this Waiver request complete and acceptable; please let me know
if the need for further information arises. Since dredging must be done prior to June 1, 1997,
your early consideration of this request would be greatly appreciated.
Very truly yours,
DOC;~KO, INC..
Keith B. Neilson, P.E.
KBN:cmc
Enclosures
cc: Hay Harbor Club
ACOE: Jim Haggerty
DEC: Hamilton
File: HAY-HARB.APP
95-19-3 (6/95)--7e DEC APPLICATION NUMBER DISTRIBUTION
1st COPY Permit Administrator
NEW YORK STATE ~-~lr'~l 2nd coPY Corps of Engineers
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
UNITED STATES ARMY CORPS OF ENGINEERS US ARMY CORPS APPLICATION NO 3rd COPY Program
4th COPY NYS Agency
JOINT APPLICATION FOR PERMIT - th coPY App,cant
P/ease read ALL instructions on back before completing this application. Please type Or print ctearly in ink. Attach additional information as needed.
[] FRESHWATER WETLANDS [] TIDAL WETLANDS [] WATER SUPPLY [] LONG ISLAND WELL
[] PROTECTION OF WATERS FOR:
[] A. Construction or placement of docks and moorings [] B. Construction, reconstruction, or repair of a DAM or other impoundment structure
[] C. Disturbance of a STREAM BED or BANKS or excavation in or till of NAVIGABLE WATERS [] 401 WATER QUALITY CERTIFICATION
[] COASTAL EROSION CONTROL [] LAKE GEORGE PARK COMMISSION (Docks and Moorings) [] WILD, SCENIC OR RECREATIONAL RIVERS
[] AQUATIC PEST CONTROL FOR: [] A. Aquatic Vegetation Control [] B. Fish Control [] C. Insect Control
1. LIST PREVIOUS PERMIT/APPLICATION NUMBERS AND DATES (if any) IF OTHER THAN INDIVIDUAL, PROVIDE
TAXPAYER ID NUMBER
I
2. APPLICANT IS A/AN [] Owner )(~] Operator [] Lessee [] Municipality/Governmental Agency (Check as many as apply)
3. NAME OF APPLICANT (Use Full Name)
Hay Harbor Club
MAI LING ADDRESS TELEPHONE 0Nhere can be reached during dayl
Be] l Hill Avenue ( 51 6 ) 788-7323
POST OFFICE t STATE I ZiP CODE
Fishers Iai ~nr~ NY 06390-
4. NAME OF [] Owner ~ Agent/Contact Person (Check one)
Docko, Inc. ~ Keith B. Neilson, PE
MAILING ADDRESS TELEPHONE (Where can be reached during day'~
P 0 Bxo 421, 18 Stafford STreet (860) 572-8939
POST OFFICE [ STATE I ZIP CODE
Mystic CT · 06355.
5. PROJECT/FACILITY LOCATION (Mark location on map, see Number la on reverse side)
Suffolk I Southold IVillageFiShers Island
Town or city
County
STREET ADDRESS/LOCATION (If different from applicant)
Same
POST OFFICE I STATE ZIP CODE DEC USE ONLY
NYTM-E NYTM-N 4
6. NAME OF STREAM OR BODY OF WATER Hay Harbor
7. HAS WORK BEGUN ON PROJECT? tf YES, attach explanation on starting work without permit, include dates. 8. PROPOSED STARTING DATE
Show work on map and/or drawing. [] Yes '~No May 1997
9. APPROXIMATE COMPLETION DATE 10. PROPOSED USE: I 11. WILL PROJECT OCCUPY STATE LAND?
May 1 997 ~Private [] Public [] CommercialI X~Yes [] No
12. PROPOSED PURPOSE:
Maintain a safe diving area.
13. PROJECT DESCRIPTION: (e.g. quantity and type of material to be excavated, dredged or used for fill or rip rap; location of disposal sites; type of
structure to be installed; height of dam; size of impoundment; capacities of proposed water sources; extent of distribution system; size of marina
and type of docks and moorings to be installed; etc.)
Maintenance dredging of the diving area at the Hay Harbor Club swimming dock from the
area shown in the attached drawings.
14. WILL THIS PROJECT REQUIRE ADDiTtO'NAL FEDERAL, STATE AND/OR LOCAL PERMITS? ~ Yes [] No If yes, please list:
Twon of Southold Board of Trustees Waiver requested.
15. Separate Authorization or Letter of NO JURISDICTION Should be Received from DEC and the US Army Corps Prior to Initiation of Work In Wetlands
and Waterways.
I hereby affirm that information provided on this form and all attachments submitted herewith is true to the best of my knowledge and belief.
Fa/se statements made herein are punishable as a Class A misdemeanor pursuant to Section 210.45 of the Penal Law. Further, the applicant accepts
full responsibility for all damage, direct or indirect, of whatever nature, and by whomever suffered, arising out of the project described herein and agrees
to indemnify and save harmless the State from suits, actions, damages and costs of every name and descrip[ion resulting from said project. In addition,
Federal Law, 18 U.S.C. Section 1001 provides for a fine of not more than $10,000 or imprisonment for not more than five years, or both, where an
applicant knowingly and willfully falsifies, conceals, or covers up a meteriai/f~'ct; or knowing{y makes or uses a false, fictitious or lraudulent statement.
X~l hereby authorize the agent named in Num~ 4,>,~bo~to.,~m/~t~ application on my behalf.
./~ /'~1 ' E 'OF' TITLe
President, Docko, Inc.
D2A~E28-97 SI TITLE
~ 14-16-4 (11195)--Text 12
PROJECT I.D, NUM6ER
617.20 SEQR
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only
PART I--PROJECT INFORMATION (To be completed by Applicant or Project sponsor)
1. APPLICANT/SPONSOR I 2. PROJECT NAME
Hay Harbor Club I Maintenance Dredging
3. PROJECT LOCATION: "
Municipality Fishers Island, Town of Southold County Suffolk
4. PRECISE LOCATION (Street address and road intersections, prominent landmarks, etc., or provide map)
The Hay Harbor Club is located on Fox Road just north of Bell Hill on Fishers Island.
The maintenance dredging is required at the swinl~i~g dock in the 'diving area.
5. ~s PBOPOSED ACTION: Maintenance of an existing facility.
[] New [_J Expansion L_J Modification/alteration
6. DESCRIBE PROJECT BRIEFLY:
THis project is to dredge approximately 3 feet of sand from the diving area measuring
approximately 20' x 25' THe sand will be removed via clam shell bucket, deposited
upland at the Mobil Dock in West Harbor and then transported bact to the site to be
deposited on the swimming beach by the south dock landward of the high tide line.
7. AMOUNT OF LAND AFFECTED:
Initially 0.01 acres Ultimately 0.01 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 [] Par~ForestlOpen space [] Other
Describe:
The land around Hay Harbor is used for residential purposes with the exception of
the club which is recreational.
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) and permitlapprovals
.' Town of Southold Waiver for Tidal Wetlands Permit.
11. DOES ANY ASPECT OF THE ACTION HAVE A CURRENTLY VALID PERMIT OR APPROVAL?
~ Yes [] No Il yes, list agency name and permit/approval r~t"te sw~]mlng dock was partially reconst-
ructed after being damaged by Hurricane Bob in 1992. Reconstruction permits were
obtained from the NYS DEC, Army Corps of Engineers and Town of Southold..
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
Hay Harbor~Club, Richard Duggan, Manager
D~te:
2-28-97
If the action is in the Coastal Area, and you are a state agency, complete the
Coastal Assessment Form before proceeding with this assessment
OVER
1
PART ii--ENVIRONMENTAL ASSESSME ('fo be completed by Agency)
A. DOES ACTION EXCEED ANY TYPE I THRESHOLD IN 6 NYCRR, PART 617.127 If yes, coordinate the review process and use tile FULL EAF.
[] Yes [] No
B. WILL ACTION RECEIVE COORDINATED REVIEW AS PROVIDED FOR UNLISTED ACTIONS IN 6 NYCRR, PART 617.67 if No, & negative declaration
may be superseded by another involved agency.
[] Yes [] No
C. COULD ACTION RESULT IN ANY ADVERSE EFFECTS ASSOCIATED WITH THE FOLLOWING: (Answers may be handwritten, if legible)
Cl. Existing air quality, surface or groundwater quality or quantity, noise levels, existing traffic patterns, solicl waste production or disposal,
potential for erosion, drainage or flooding problems? Explain briefly:
C2. Aesthetic, agricultural, archaeological, historic, or other natural or cultural resources; or community or neighborhood character? Explain briefly:
C3. Vegetation or fauna, fish, shellfish or wildlife species, significant habitats, or threatened or endangered species? Explain briefly:
C4. A community's existing plans or goals as officially adopted, or a change in use or intensity of use of land or other natural resources? Explain briefly
C5. Growth, subsequent development, or related activities likely to be induced by the proposed action? Explain brielly.
C6. Long term, short term, cumutative, or other effects not identified in C1.C57 Explain briefly.
C7. Other impacts (including changes in use of either quantity or type of energy)? Explain hriefly.
D. IS THERE, OR IS THERE LIKELY TO BE, CONTROVERSY RELATED TO POTENTIAL ADVERSE ENVIRONMENTAL IMPACTS?
[] Yes [] No If Yes, explain briefly
PART IIImDETERMINATION OF SIGNIFICANCE (To be completed by Agency)
INSTRUCTIONS: For each adverse effect identified above, determine whether it is substantial, large, important or otherwise significant.
Each effect should be assessed in connection with its (a) setting (i.e. urban or rural); (b) probability of occurring; (c) duration; (d)
irreversibility; (e) geographic scope; and (f) magnitude. If necessary, add attachments or reference supporting materials. Ensure that
explanations contain sufficient detail to show that all relevant adverse impacts have been icientifled and aciequately addressecL
[] Check this box if you have identified one or more potentially large or significant adverse impacts which MAY
occur. Then proceed directly to the FULL EAF and/or prepare a positive declaration.
[] Check this box if you have determined, based on the information and analysis above and any supporting
documentation, that the proppsed action WILL NOT result in any significant adverse environmental impacts
AND provide on attachments as necessary, the reasons supporting tiqis determination:
Print or Type Name of Responsible Officer in Lead Agency
S~gnature of Responsible Officer in Lead Asenc¥
Name of Lead ^sency
Date
Title of Responsible Olficer
Signature of Preparer (if different from responsible officer)