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. , � � i <br /> ` ' , . � �'NVIRONb'fENTAL CFiECKLIST � � <br /> , � ($25. 00 Fee Required) <br /> Introduction: The State Environmental Policy Act of 1971, � <br /> Chnpter 43.21C , RCLV, requires all state aZd local governmental <br /> ngencies to consider environmental values both for their own <br /> nctions and when licensing private proposals. The Act also <br /> reqaires that an �IS be prepared for ail major actions significantly <br /> , affecting the quality of the environment. The purpose of this <br /> checklist is to help the agencies involved determine tvhether or nnt <br /> a proposal is such a major action, e <br /> Flense answer the following questions as completeIy as you can <br /> wZth the information presently available to yau. 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 /> explanetion in the space provided, or use a i ional pages if ' <br /> necessa-y. You should include references to any ^eports or studies <br /> � of which you are aware and which are relevant to the answers you <br /> provide. Complete answers t� these questions now wili help all <br /> . agencies involved with your proposal to undertake the required <br /> enuironmenfal review without unnecessnry delay. . . <br /> The following questions apply to your total proposal, not just to the � ' <br /> � lice�ise for �vhich you are currently applying or the proposal for <br /> N•hich approval is sought. Your answers should include thc impects <br /> which will be cuused by your proposal when it is completed, even <br /> though completion may not occur until sometime in the future. This ' <br /> will ail'otv all of the agencies which will be'involved to complete <br /> . their environmental revieN� now, without duplicating paperwork in . <br /> the future. . <br /> • NOTE: This is a standurd form being u�ed by all state and local � <br /> agencies in the Stnte of�Yashington for various types of proposals. <br /> 114any of the queshons mny not apply to you: proposal. If u question � <br /> does not a.pply, just ans�ver it "no" and continue on to the next <br /> question. ' <br /> ENVIRONMENTAL CHECFCLIST FORM � • <br /> I. BACKGROUND • <br /> 1. . Nume of Proponen: �� � ` ' 1 <br /> 2. Ad ress nnd Phone Number of Proponent: :•���;:. <br /> � : �� .,� ,o �.� ��.�ti .�/ o�t y�o3G �: . � <br /> . , <br /> ' 1 <br /> 7-7 - O l c�-- _. 7 7 cLz� �� <br /> • .3. Date Checklist SuUmitted . <br /> ` 7/ <br /> -- ----- � <br />