HomeMy WebLinkAbout1000-35.-2-8 OFFICE
CHall Annex MAILING ADDRESS:
Town ° � DKK^ P.O. Box 1179
54375 State Route 25 "M, Southold, NY 11971
(cor. Main Rd. &Youngs Ave.)
Southold, NY � Telephone: 631 765-1938
www.southoldtownny.gov
PLANNING BOARD OFFICE
TOWN OF SOUTHOLD
MEMORANDUM
To: Scott Russell, Town Supervisor
Members of the Town Board
Denis Noncarrow, Town Clerk
From: Donald J. Wilcenski, Chairman ct,�
Members of the Planning Board
Date: November 16, 2022
Re: Change of Zone Applications
• RQA Properties LLC, 29950 Route 25, Cutchogue, SCTM#1000-102-3-1
4 4545 Main Road Enterprises, Inc., 4545 Route 25, Greenport, SCTM#1000-35-2-8
The Planning Board has reviewed the zone change requests referenced above. The
recommendation is to postpone any decision-making on these and future zone change requests
until the Zoning Update currently under way is completed.
An exception to this recommendation would be for Affordable Housing District zone change
requests, which, as a floating zone, is appropriate to consider given the great need in Southold
Town.
DENIS NONCARROW n � " Town Hall,53095 Main Road
TOWN CLERK P.O.Box 1179
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS � a Fax(631)765-6145
MARRIAGE OFFICER Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER MMYW " www.southoldtownnygov
FREEDOM OF INFORMATION OFFICER
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD RBALMr .ec.
RECEIVED
MAY 0 5 2022
until' own
Planning Board
To: John Burke, Deputy Town Attorney1'i�r'r- y `ad 1c)) \
Heather Lanza, Planning Director re,�erc!- S14
From: Denis Noncarrow, Town Clerk
Re: Change of Zone Application of 4545 Main Road Enterprises, Inc.
Date: September-30,-2'`" resent May 4,2022
Please review the enclosed change of zone application as to completeness and send me your
comments and recommendations. Thank you.
Enclosure (1) Application
NAME OF APPLICATION: 4545 Main Road Enterprise,Inc.
DATE: September 30,2021
❑ Check means item is complete ❑ Circle means item not complete
CHECKLIST FOR RE ZONING PETITION
TC TA PB
D ❑ Four(4) complete copies of petition with Town Clerk with original signatures. Each set
MUST be ordered as follows:
❑ Fee of$1,000.00 ($500.00 for AHD)
Q ❑ Written notice to all property owners within 200' of property; mailed within 5 days
/
ftg�LqLILilg filing of petition
hY" 0 ❑ File proof of mailing of notices to adjacent property owners in a sworn statement with
Clerk's office and submit all original certified mail postal receipts
NOTICE MUST CONTAIN:
* Statement Of Proposal (as presented in zoning petition)
O Description Of Property
* Present Zone And Proposed Zone
* Petition Will Be Filed Within 5 Days
* Petition Can Be Reviewed In Clerk's Office
* Public Hearing Must Be Held
* Adjacent Owners Right To Be Heard @ Hearing
* 10 Days Before Hearing Notice Published
❑ 0 ❑ Meet all requirements for submitting zoning action pursuant to section 239 L&M of General
Municipal Law attached hereto
��J ❑ If applicable, file waiver of notice from property owner w/the clerk's office
i
i::! ❑ Six (6)maps drawn at the V= 100' scale in accordance with attached information sheet.
im ❑ Six (6) sketch plan maps at the 1"= 100' scale or the 1"=20' scale in accordance with
attached information sheet.
The procedural requirements appear to have been met by this application:
Town Clerk .....:. _. �...�./ Date211
..
Signature
TownAttorney _. w .._.................................................. Date_................._.
Signature
Planning Board Date
Signature
RECEIVED
Michael A. Kimack
ATTORNEY AT LAW
P.O. Box 1047 Southo!d Town Clerk
Southold,N.Y.11971
�..�Cell No. 516-658...-6807....................................._
E-mail: mkimack2@verizon.net
September 18,2021
Ms. Betty Neville, Town Clerk
Town of Southold
P.O. Box 1179
Southold,N.Y. 11971
Re: Petition of 4545 main Road Enterprises, Inc. to Southold Town board for Change of Zone
Premises: 4545 Main Road, Rt.25, Greenport
SCTM# 1000-35- 2 - 8
Dear Ms.Neville
The property has been utilized for commercial enterprises since the late 70's. For approximately
the last forty (40)years, the property has been occupied with a building operating as a restaurant.
We respectfully request the property be re zoned from its present R- 80 zone to limited Business
(LB). This zone would allow the property owner to convert the property to other commercial
uses as permitted by the zoning code for a limited business zone
Enclosed please find the following:
1. Four sets of the completed application form and petition with aerial photo
2. Check for the application fee of$1000.00
3. Six(6) prints of Map for Zoning Change and list of property owners within 500 feet
4. Six (6)prints of updated survey of property
5. Copy of the deed containing metes and bounds description
6. Short Environmental Assessment Form
7. Proof of mailing service
8. Property card
9. Summary of commercial activities in surrounding area
Notice to Adjoining Property Owners within 200 feet with attorney affirmation of service is
enclosed
Sincerely,
Michael A. Kimack, Agent
i%/ii i
ELIZABETH A.NEVILLE MMC �//i i �� Town Hatt,53095 Main Road
TOWN CLERK
/� i,,°% P.O.Box 1179
:; ���, ��j%
Southold,New York 11971
REGISTRAR OF VITAL STATISTICS ,�1��/�� Fax(631)765-6145
MARRIAGE OFFICER Telephone(631)765-1800
RECORDS MANAGEMENT OFFICER www_southoldtownnygov
FREEDOM OF INFORMATION OFFICER
RECEIVED
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD SEPI 0 2021
REQUEST f'OR A E- MENT gtr 'I IDR C ANGE OF 7,0NESouthcr,d Town Cerk
APPLICATION NAME:
(N IN,
SUFFOLK COUNTY TAX.MAP NO.: 1000 - ......M.., _—15_ -_ Z -_—'8—
District Block Parcel
A. SUBMISSION INFORMATION:
Application is hereby made to the Southold Town Board for amendment to Chapter 280
{Zoning) of the Town Code and/or a change in the zoning classification of the Zoning
Map in accordance with the Section 280 - 6 of the Zoning Law of the Town of Southold
and Section 265,Town Law.
Further,the following are submitted herewith (check tiro :w ar o nriate. Ni,r•ite N/A
here not applicable)
—6. Four(4) sets of the completed application form and petition. Each set shall contain
one (1) complete set of cover letter forms, affidavits, project description, surveys,
plans, and EAF and any supplemental information as maybe be needed or requested.
tl'*""2. Fee in the amount of$1,000.00 ($500.00 for AHD). Applicant is also responsible for
any fees incurred in the Environmental Review Process.
3. Survey map, accurately drawn to appropriate scale, showing the proposed zone
district boundary changes,property lines, the calculated areas affected, in acres or
square feet, the Suffolk County Tax Map designations, the street rights-of-way in the
immediate vicinity and lands, land uses and names of owners immediately adjacent to
and extending within five hundred (500) feet of all boundaries of the property to be
amended.
_Z4. Metes and bounds description of the proposed amendment.
10/1/2008 1
—�Z 5. Appropriate Environmental Assessment Form (EAF). All Unlisted and Type I
Actions require either a Short or Full EAF to be prepared. See Chapter 130 of
Town Code and Part 617 NYCRR (SEAR), or check with the Town Attorney and/or
the Planning Department.
��6. Other information deemed necessary for review by the Town Board,the Town
Planning Board and/or the Suffolk County Planning Commission(i.e. site plans,
subdivision maps). Please note items submitted:
�" X » .
B. GENERAL INFORMATION:
1. Name Of Applicant( )
Address:
_. .� ..... ......................... _.
Tele hone No.
If the applicant does not own the property, is a contract vendee, or if the owner is
a Corporation or a Partnership,prepare endorsement at the end of this form
establishing owner's authorization of the applicant's request.
2. If the applicant is contract vendee, give name. If the applicant is a corporation(or
partnership), give the name and title of the responsible officer:
Name: Title:
Address:(if different)
Telephone No..
3. Landowner(s) C1. � Title;Address _._..�� . ... ..�
Telephone ...... www. I . �'" �.�.1?��4 CL>
Tele hone No, - ...
4. Name of licensed architect, landscape architect, civil engineer and/or surveyor who
prepared the plan:
Name:._ . W.,C � Title:.
Name of Firm:
Address: 'fix. ". ,��,�_ ''' "�+ � �6/ r . '' 11' �-..._.._
Telephone No.:.... _ . 3 .."
P . �. ,_ _... ...... ..... _o- . ...,.,.,. . .,e.,._
5. Name of Attorney, or Agent authorized to represent the property owner and/or applicant:
Name: "` `�� w ..... � � ..............._Title: -r
Name of Firm.
Address: ` .��� 1� � IVY 11Y-7 .
Telephone No.: �'". ....,. __....... .... ._...._..
10/1/2008 2
6. All communications with regard to this application shall be addressed to the following
person until further notice:
Name:
Address
Telephone No.:---,- -___._�. _....
C. SITEXROJECT DATA:
1. Location of Property w . of
nord uh east/we st
(street)
11," &OA1_, QQ feet.... ......._..... _.._w.
or road) (north/soutl,
of .... .. �.., � '�
(nearest intersecting street) (hamlet)
2. Existing zoning districts)_ �`--
Special Overlay District(s), if applicable _.. . .....
3. Requested zoning districts 1. � L) =WY_w.. � .
4. Lot area:, -.,,,,-- sq. ft or acres__www..0-6..4_...,_.ww...._...................._.._w.._____.....
5. a. The latest deed(s)describing this parcel(s) is (are)recorded in the County Clerk's
Office as follows:
DA FF LIBEL PAGE
201fa-00-_..
b. A copy of the(se) should be attached to the application.
6. There are no encumbrances or liens against this land other than mortgages?
YES _. .w.w.._NO
7. All buildings and structures are shown on the survey?_ �YES NO
(The Town Board reserves the right to request a complete survey showing all existing
structures.)
S. Existing: Building Area � r sq. ft. Lat coverage_ F_6 �0
9. Please attach a detailed typewritten description of the project,the proposed use and
operation thereof. including a detailed explanation of the design concept,the reason for
the particular design, objective of the developer or project sponsor and how or why the
project is (or is not)in compliance with the Town Code and the Master Plan. Explain
what benefits will accrue to the community by the proposed rezoning. Document reasons
10/1/2008 3
k\hy proposed project can nal be huilt under current zoning regulations and pursu,ult to
the C1.11'1-ent '7.011111',? 111up.
D. AGENCY COORDINATION AND SEQRA (See Part 617. NYCRR and Chapter 130 of
Tovv n Codc)
1. Does the site Front on a Town. County of State Road`' (circle ogle)
Name and number of the road (i.c. C'0unty Road 48. State Road 25)
?. Is the site v�ithin ani other areas of'review ofthe Suffolk County Plaorling Con1111ission?
YF B
S NO, 'y'es, the referral requirements ofthe Suffolk CountN
Planning C'0nlnliSSion should be examined to assure a complete application.
3. Is the site in a designatcd Critical environmental area as per the New York State
I:llvironniental Quality Rewievv-Act (SL-;()IC,\) and Chapter 1300 of the Town Code?
-.......... YES I.......V' NO. Ifyes. %%hat ,area'
4. Fype I. '1 N.-pc 11 or Unliswd Action (CINIC'Onl')
All environmental ;ksscssnlerlt 101-111 111U,il be ,olnpleted for Unlisted and Type I actions.
5, Has an F.11virllswmc Ill Assess111ent Form or Dralt Environmental Impact'Staternent been
Ilrcpared? F 'S Il'yes. copies should be submitted with the
application.
E. F hereby depose and certify that ,all of the aboie statements of information,and all
statements and information contained in the supporting documents and drawings
attached hereto are true and correct.
APP1,.1CANT'S S16NA 11If1;
ti��urn hefOre lllu .his Telephone Nuntbe,'
d o f _ 't1 $J
• c-mail address ' , Y'4&A-r �/C(,ptJ� CO-V
_.. ....
No I.WY P(F 1 6C"
MICHAEL A.KIIIrIACK
Notary Public,State of Now York
No.02 105 6
Oualiffed In Nassau County
Commission Expires March 11,
10/112008 4
F. OWNER'S ENDORSENIENT ( Fo be sI,gned ji'applicant is n(It the mwner or if the omier
is a corporation or partnerdi'113)
State of New York
County of S U ffio I k
--heing, duly sworn- deposes and
sans that hq,iIljeresides ell J:
A9
III the ('01.111ty Of and the State
and that heQvis (the owner or the officer of the corporation or partnership which is the owner
in 1,ce (Circle)) of the premises described ill the f*()re(-,,-)Iri,(, application and that heeha,,,
'11.1thOl-i/Cd
to make the f6rcooing application lloramendmeiit and/or change of zone as described here in.
NV","A
m 1:
SIGNATURE
H-2yN
ffa corpmalioll. namo O�'corporation and
Officer's title
S 01
111C this
Din 20-,Z/
MICHAEL A.WMACK
Notary Public,$We of New York
No�02KI50SM23
Cluallfied In Nassw CourdY
Cornmission Expires March 11,2022
10/1/2008 5
G. DISCLOSURE AFFIDAVIT
State of New York
County of Suffolk
S" = " being by me duly sworn, deposes and says:
1. I am an applicant for a project or 11n owner fthe land which is the subject of a pending
application before the Southold Town : salt°d for amendment and/or change of zone.
2. The project name is: �" �... � ... .w . .,. ....... ° � _
3. I reside at
4. The Officers of the applicant corporation or owner corporation are as follows:
NAME TITLE
w.wwww.ww......... _. .. ........... .. � , �....... .a.aa._._.
5. I make and complete this affidavit under the penalty of perjury and swear to the truth
herein.
6. I am aware that this affidavit is required by General Municipal Law 809 and that I shall
be guilty of a misdemeanor as provided by General Municipal Law 809 should I
knowingly or intentionally fail to make all disclosures herein.
7. During the 12 months before the filing of this application,have any of the following
individuals made campaign contributions exceeding$100 in total, in cash or in kind,to
members of the Town Board or political committees designated to accept donations
behalf:
Yes No�
1. Owner
2. Applicant
3. Agent for owner or applicant _ t�
4. Attorney w.... .,.,a _.._
5. Other
10/1/2008 6
If the answer to Question 7 is yes,Town Code Chapter 26 require that the information be
provided below:
Name Title (0witer, AgyentAttorneys, other) Amount
***********4*****,***********t,****************************4
For the purpose of this disclosure, an official or employee or either the Town of Southold or the
County of Suffolk, shall be deemed to have an interest in the applicant and or owner when that
official or employee, their spouse, brothers, sisters, parents, children, grand children or the
spouse of any of them:
a. Is the applicant or owner
b. Is an officer, director,partner, or employee of the applicant or owner
c. Legally or beneficially owns or controls stock of a corporate applicant or owner,
or is a member of a partnership or association applicant or owner, or
d. Is a party to an agreement with the applicant or owner, express or implied,
whereby said official or employee may receive any payment or other benefit—
whether or not for services rendered, dependent or contingent upon the favorable
approval of such application.
Ownership of less than five percent of the stock of a corporation whose stock is listed on the
New York Stock or American Stock Exchanges shall not constitute an interest for the purposes
of this disclosure
YOU MUST ANSWER THE FOLLOWING QUESTION YES OR NO
Do any of the following indiN idpals have an interest in the applicant or owner, as defined above?
"YES NO
1. Any official New York State 2 YES k"..'NO
2. Any official or employee of§`o`u_ hold"Town or Suffolk County?—YES NO
If the answer above is yes,to any of the questions, General Municipal Law Section 809 requires
that you disclose the name and residence and the nature and extent of the Interest of said
individual (s) in the applicant or owner.
NAME RESIDENCE NATURE OF INTEREST
............................... ...... . ........ ........................... ......
10/1/2008 7
SIGNATORE
Sworn before me this
LMv of_._. � 20�
NOTARY PUBLIC
MICHAEL A.10MACK
Notwy Public,State of Now York
No.0,2KIS056M
Oualffied In Nassay Courty
Commission Expires March 11,
1011!2008 8
617.20
Appendix B
Short Environmental Assessment Form
Instructions for Conipletin
Part 1-Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses
become pail of the application for approval or funding,are subject to public review,and may be subject to further verification
Complete Part I 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 I-Project and Sponsor Information
�'412-46W-7�- .X- 16
-Name—of-Action or Project:
Project Location(describe,and attach a location map):
Brief Description of Proposed Action:
7—a 6-01V'Ve!5,R 7— /:;7k��Al
............
Narne of Applicant or Sponsor: Telephone.
Address:
C7
ity/M State. Zip Code: *y J
1,Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES
administrative rule,or regulation?
If Yes, attach a narr�ative description of the intent of the proposed action and the erivii,oiunental resources that
may be affected in the municipality and proceed to Part 2. If no,continue to question 2.
............ 4
2. Does the Proposed action require a pen-nit,approval or funding Frain any othcr govemmental Agency? NO YE,S.-
If Yes,list agency(s)name and permit or approval:
..... ............... .....
acres
3,a.Total acreage of the site of the proposed action?
b.Total acreage to be physically disturbed? acres
c.Total acreage(project site and any contiguous properties)owned
or controlled by the applicant or project sponsor? acres
.......... .......-""" .......
4. Check all land uses that occur on,adjoiningand near the piopos d action,
1:1 Urban LJ Rural(non-agriculture) C1 In4 V'*orrrriercial )(Residential(suburban)
Ll Forest c-Agriculture 0 Aquatic X Other(specify): &&A C019'415.............
c]Parkland
..............
Page 1 of 4
5. ro
the proposed aNO",
I5 , ,.�........._._� ..�....... _ _.,�. .,.._-w .,w.m..� _.a_ ..........__._._.ww..__� �,�.... ...
Y p p action, ES N/A
a.A permitted use under the zoning regulations? x NW
b.Consistent with the adopted comprehensive plan?
6, lIs the andscape?peposed action consistent with the predominant character of the existing built or n W.
atural NO YES
,....
ry
7. Is the silo of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NOw M YES m
If Yes,identify: _,,,_,,_,,, j
. ....ww_............ ....M........ W.... ..
8, a.Will them proposed action result in a substantial increase in traffic above wmpre �....
p p Bove present levels? NO YES �
b.Are public transportation service(s)available at or near the site of the proposed action?
c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action?
i
9.Roes the proposed action meet or exceed the state energycode requirements? NO YES
If the proposed
tion
ac., ,describe design features and technologies,
�,.will exceed requirements ....._ ...._ X
._.:
10. Will the proposed action connect to an existing public/private water supply? NO YES
If No,describe method for providing potable water: .._.
_ _
_..._....... ..
11.Will the proposed...actiog wastewater utilities?
n connect to existing -_ ......._,.w_ww.�..� _.....
p ....,... NO YES 11
1
If No,describe method for providing wastewater treatment .
12. a.Doeshe site contain a structure that is listed on either the State or National Register of Historic NO YES
Places? X
b,Is the proposed action located in an archeological sensitive area? ._.. _
13,a Does any wetlands a portion then wat rbodres reeulated b da federal,state nds adjoining the 7ro proposed action, O Y
.. on,or l
a j g P P contain N ES` V
g y ate 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
- "
14. Identify typical habitat that occur on theproject Check all that apply:
El Shoreline Forest ❑Agricultural/grasslands ❑ Early mid-successional
O Wetland ❑Urban O(Suburban
15,Does the site of the proposed action contain ... species
..ani ���..... hab s, ��t ����������� ��� .
any species of animal,ar associated habitats,listed NO ; YES
by the State or Federal government as threatened or endangered? �(
..W................._._..._._� ,kww_ wwww...... .. , ,,,,,, .. .. .......
�w...._ ... ..,
lb.Is the project site located in the 100 year flood plain? NO YES
17.Will the proposed action create storm water discharge, p. int or non-point
So es? � ES k
.......,. .. ... �. .....__ either from p
Dint or non- Dint sources. NO YES
If Yes,
a.Will storm water discharges flow to adjacent properties? O NO❑YES X
b.Will stone water discharges be directed to established conveyance systems(runoff and storm drains)?
If Yes,briefly describe: ❑NO O YES
Page 2 of 4
18.Does the proposed action include construction or other activities that result in the impoundment of NO YES
water or other liquids(e.g.retention pond,waste lagoon,dam)?
If Yes,explain purpose and size:
.............................
..........I............... ......
19.Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES
solid waste management facility?
If Yes,describe:
.......... ........
-—--......... ........--- . .......
20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES
completed)for hazardous waste?
If Yes,describe: ...... ......... ......
I AFFIRM THAT THE INFORMATION PROVIDED ABOVE TS TRUE AND ACCURATE TO THE BEST OF MY
pOWnt/spon
Asor name: 0-0yDate:
Signature:.
Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the following
questions in Part 2 using the information contained in Part I and other materials submitted by the project sponsor or
otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my
responses been reasonable considering the scale and context of the proposed action?"
or"111 Mo4erlatev
small to large
impact 1 impact
may may
occur occur
......... .......... ................. ....................... .........
1. Will the proposed action create a material conflict with an adopted land use plan or zoning
regulations?
............
2. Will the proposed action result in a change in the use or intensity of use of land?
3. Will the proposed action impair the character or quality of the existing community?
XmW
4. Will the proposed action have an impact on the environmental characteristics that caused the
establishment of a Critical Environmental Area(CEA)9
................... ..........
5. Will the proposed action result in an adverse change in the existing level of traffic or
affect existing infrastructure for mass transit,biking or walkway?
.......... .............
6. Will the proposed action cause an increase in the use of energy and it fails to incorporate
reasonably available,energy SRnsenlati0f)or renewable energy cppoltumtles?
7. Will the proposed action impact existing:
a.public/private water supplies?
b.public/private wastewater treatment utilities?
8. Will the proposed action impair the character or quality of important historic,archaeological,
architectural oi-aesthetic resources?
9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands,
waterbodies,groundwater,air quality,flora and fauna)?
... .................
Page 3 of 4
No,or Moderate
small to large I
impact impact
may may
10. Will the action in increase in the for. ._..e.. w�ww .w... w.....,�...
occur occur
P p potential erosion,flooding or drainage
problems?
ro osed action create a hazard to environmental resources or human... .w....�.._.................._.._.
11. Will the . ......_
proposed n health?
Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every
question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular
element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3.
Part 3 should,in sufficient detail,identify the impact,including any measures or design elements that have been included by
the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact
may or will not be significant.Each potential impact should be assessed considering its setting,probability of occurring,
duration,irreversibility,geographic scope and magnitude. Also consider the potential for short-term,long-term and
cumulative impacts.
11 Check this box if you have determined,based on the information and analysis abort adverse s �portmg
e,and an su documentation,
that the proposed action may result in one or more potentially large or significant impacts and an
environmental impact statement is required.
❑ Check this box if you have determined,based on the information and analysis above,and any supporting documentation,
that the proposed action will not result in any significant adverse environmental impacts.
.... _ ...., _. _........�..... _ .... .. . ...a,... �..... ..._. w.......
Name of Lead Agency Date
Print or Type Name of Responsible Officer in Lead Agency _............ Title of Responsible Officer
......... miW _ .. .
Signature of Res onsible Officer in Lead A enc Signature of'Pre arer(if different fi•om Responsible Officer)
Page 4 of 4