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� ($50.00 I�cc Itequired) <br />Introduc[ion: The State L•'nvironmeneal Policy Act of 1971, ChapCer 43.21C, BCW, require, all <br />st�Le and local governmental a�encies to consider environcir.ncal valucs botL for Lhcir o�,m <br />actions and when licensing private propnsals. The hct also requires that an ETS be prepared <br />for all major acCinns siqni[icantly affectiAF; the quality of the environment. The purpose <br />of Lhis checklist is to help the agencies,involved determine whether or not a proposal is such <br />a ma3or action. . <br />Please answer the following questions as compl.etely as you c<1n with the information presently <br />+_vailable [o you. Where ex.planations of your answers are requi.red, or where you oelie��e an <br />explanation would be helpEul to governTent decision makers, include your explanacion in the <br />spac� provided, or use additional aages if necessary. 1'ou shquld include references to any <br />reporl•s or studies of wnich you are acaare nnd which are relevant to the answers you pro�•iJe. <br />Complete answcrs io these questions now will help all agencies involved with your proposal <br />to undertake the required environnental revieia without unnecessary delay. <br />The folloo�ing questions apply to your total proposal, not just to the license for �ah=.ch ��ou <br />are currently applying or the nroposal Lor whicli approval is sought, lour ans�aers shculd <br />include the inpacts i.•hich taill be caused by your proposal when it is completed, e�•cn Lhough <br />comple[ion may not occur until sometime in the future. This caill all.ow all of the a�encies <br />t�hich will be involved to complete their environmental revieca noca, iaithout duplicati.ng <br />paper work in the future. . , ' <br />NOTE: This is a standard form being used by all state and lo�� �g�Rc��',�n t[�e�,�ate of <br />Washington for various types of proposals. Tfany oi the quest o��s ma�7 t apply 'toJyour ;�roposal. <br />If.a q_uestion does not apply, just ansmer it "no" and continue o� to the �e�t�9uestion. <br />��� 1 .5 i�, . <br />ENl�IRO:^iBNTriL Ct1CCI:LIST FOR`f OF �v��'I_j� <br />1. BACKGRDUP,� CtTY,�'�y� b �ept. <br />1. Name of Proponent (�� /7f�+��C�� ���/'�7 <br />2. Address and Phone Number of Proponent: Z— O. � Gy(G{Z�[S (,�%;,i <br />' . -li�'O�O <br />3. Date Checkli.st Submitted <br />4. Agency Bequiring Checklis <br />—/3— 7 <br />�,��� <br />5. Name of Proposal, if applicable,: f��'`�/-jG �`'f„����FN�� __ <br />6. Nature and Brief Description of the Proposal (includin�; but not limited [o i[s size, <br />general design elements, and other factors that will give an accurate understandi�g <br />of its scop� and nature) : /�/ [i i� SE/2� ��� v�3'.4�: _ <br />7. .Location of Proposal (descril>e ihe physical setting of the proposal, as �.�ell as [he <br />extent of the land 2re� affccted by any environmental impacts, including any ocher <br />information needed to give an accurate understanding of the em�ironment� se�tinq of <br />the proposal):-- SLtJ a'u �.Cu f3 , ��75 `f,S, 16 �� .5 1� fPlC�7�9'_/��.%/� <br />cU <br />8. EsCima�ed llatc for Comp c ion of <br />�AN C�C <br />Action: <br />'s <br />