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M _ <br />'ENVJ' �12h1%NTAL Ciil:i KL1ST y '7-•.,cv c <br />($25.00 Fee Required) <br />Introduction: The :late Environmental Policy Act of 1071, <br />Chapter 43.21C, IIC1V, requires all state and local governmental <br />agencies to consider environmental values both for their own <br />actions and when licensing private proposals. The Act also <br />requires that an EIS be prepared for all major actions significantly <br />affecting the quality of the environment. The purpose of this <br />checklist is to help the agencies involved determine whether or n6t <br />a proposal is such a major action. <br />Pleaac answer the following questions as completely as you can <br />with the information presently available to you. Where explanations <br />of your answers are required, or where you believe an explanation <br />would be helpful to government decision makers, include your <br />explanation in the space provided, or use additional pages if <br />necessary. You should include references to any reports or studies <br />of which you are aware and which are relevant to the answers you <br />provide. Complete answers to these questions now will help all <br />agencies'involved with your proposal to undertake the required <br />environmental review without unnecessary delay. <br />The following questions apply to your total proposal,' not just to the <br />license for which you are currently applying or the proposal for <br />whir•h approval is sought. Your answers should include the impacts <br />which will he caused by your proposal when it is completed, even - <br />though completion may not occur until sometime in the future. This <br />will allow all of the agencies which will be involved to complete <br />their environmental review now, without duplicating paperwork in <br />the future. <br />NOTE: This is a standard form being used by all state and local <br />agencies in the State of Washington for various types of proposals. <br />hleuy of the questions may not apply to your proposal: If a question <br />does not apply, just answer it "no" and continue on to the next <br />question. <br />ENVIRONMENTAL CHECKLIST FORM <br />1. 13ACI{GROUND <br />1. Name of Proponent s 7CJL-7- <br />2. Address and Phone Number of Proponent: <br />7-EL- 77Co `770`J <br />3. Date Checklist Submitted i0 - e[ry - <br />9 <br />