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� <br />. <br />�' ��NVIRONMBNTAL CHECKLIST �� <br />($25.00 P'ee Required) � <br />Introduntion: The State Environmental Policy Act of 1971, <br />�hupter 43.21C, RC�V, requires,all stnte und local governmental <br />agencies to consider environmental values Uotr, for their own <br />actions and when licensing privnte proposnls. The Act also <br />requires thnt an fiIS be prepared for all major actions significantly <br />r..'':ecting tha quality of the environment. The purpose of this <br />checklist is to help the ngencies involved determine cvhetlier or not <br />a proposal is such a mujor action. <br />Please ans�ver the follotiving questions as completely as you can <br />with the information presently avnilablF !u you. Where explanntions <br />of your answers are required, or where you believe an explanation <br />would be helpful to government decisian makers,.include your <br />explanation in the'space provided, or �se additional pages if <br />necessar,y. You should include references to any reports or studies <br />of which you are nware and tivhich are relevant to the ansvrers you <br />provide. Complete ans�yers to these questions novr �vill help all <br />agencies invoived with your proposal to undertake the required <br />environmental review without unnecessary delny. <br />Tne follo�ving questions apply to your total proposal, not just to the <br />license for tvhich you ure currently applying or the proposal for <br />which approval is sought. Your answers should include the impacts <br />which will be caused by your proposal when it is completed, even <br />though complerion may not occur unti] sometime in the future. This <br />will nllow all of the a�encies which tivill 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 />ugencies in tha State of FVashingtor.. for various types ot propos.ls. <br />Many of the questions may not apply io your proposal. If a question <br />does not apply, just uns�ver it "no" and continue on to the next <br />question. � <br />ENVIRONIIIENTAL CFIECKLIST FORM <br />I. BACKGROUND <br />1. Name of Proponent �F�J"%l�'� �'1 � ��-'�L �`' �" � <br />2. Address nnd Phone Number of Proponent: _ <br />I ,_,�'�t��`i��-�'� �`'/I'.- f l �-.�� I :{ r/�_I�',V!��``�. <br />/"I� r"1� 1��=�L ° �,..-r�..,. i-,,,r�l�- •f'`•, :.''�<V tJ,'C:7 'v�''I `:��= <br />w ," �- <br />3. Date Checklist Submitted �I +� I�'1-}^ <br />c <br />� <br />