Cal. Code Regs. Tit. 14, div. 6, ch. 3 app H

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Current through Register 2024 Notice Reg. No. 26, June 28, 2024

Appendix H - Environmental Information Form

(To be completed by applicant)

Date Filed ____________________

GENERAL INFORMATION

___________________________

1. Name and address of developer or project sponsor:

___________________________

2. Address of project:

___________________________

Assessor's Block and Lot Number

___________________________

3. Name, address, and telephone number of person to be contacted concerning this project:

___________________________

4. Indicate number of the permit application for the project to which this form pertains:

___________________________

5. List and describe any other related permits and other public approvals required for this project, including those required by city, regional, state and federal agencies:

___________________________

6. Existing zoning district:

7. Proposed use of site (Project for which this form is filed):

___________________________

PROJECT DESCRIPTION

8. Site size.

9. Square footage.

10. Number of floors of construction.

11. Amount of off-street parking provided.

12. Attach plans.

13. Propose scheduling.

14. Associated projects.

15. Anticipated incremental development.

16. If residential, include the number of units, schedule of unit sizes, range of sale prices or rents, and type of household size expected.

17. If commercial, indicate the type, whether neighborhood, city or regionally oriented, square footage of sales area, and loading facilities.

18. If industrial, indicate type, estimated employment per shift, and loading facilities.

19. If institutional, indicate the major function, estimated employment per shift, estimated occupancy, loading facilities, and community benefits to be derived from the project.

20. If the project involves a variance, conditional use or rezoning application, state this and indicate clearly why the application is required.

Are the following items applicable to the project or its effects? Discuss below all items checked yes (attach additional sheets as necessary).

YES	NO
___	___	21. Change in existing features of any bays, tidelands, beaches, lakes or hills, or substantial alteration of ground contours.
___	___	22. Change in scenic views or vistas from existing residential areas or public lands or roads.
___	___	23. Change in pattern, scale or character of general area of project.
___	___	24. Significant amounts of solid waste or litter.
___	___	25. Change in dust, ash, smoke, fumes or odors in vicinity.
___	___	26. Change in ocean, bay, lake, stream or ground water quality or quantity, or alteration of existing drainage patterns.
___	___	27. Substantial change in existing noise or vibration levels in the vicinity.
___	___	28. Site on filled land or on slope of 10 percent or more.
___	___	29. Use of disposal of potentially hazardous materials, such as toxic substances, flammables or explosives.
___	___	30. Substantial change in demand for municipal services (police, fire, water, sewage, etc.).
___	___	31. Substantially increase fossil fuel consumption (electricity, oil, natural gas, etc.).
___	___	32. Relationship to a larger project or series of projects.

ENVIRONMENTAL SETTING

33. Describe the project site as it exists before the project, including information on topography, soil stability, plants and animals, and any cultural, historical or scenic aspects. Describe any existing structures on the site, and the use of the structures. Attach photographs of the site. Snapshots or polaroid photos will be accepted.

34. Describe the surrounding properties, including information on plants and animals and any cultural, historical or scenic aspects. Indicate the type of land use (residential, commercial, etc.), intensity of land use (one-family, apartment houses, shops, department stores, etc.), and scale of development (height, frontage, set-back, rear yard, etc.). Attach photographs of the vicinity. Snapshots or polaroid photos will be accepted.

CERTIFICATION: I hereby certify that the statements furnished above and in the attached exhibits present the data and information required for this initial evaluation to the best of my ability, and that the facts, statements, and information presented are true and correct to the best of my knowledge and belief.

___________________________Date		___________________________
		(Signature)
	For	___________________________

NOTE: This is only a suggested form. Public agencies are free to devise their own format for initial studies.)

Cal. Code Regs. Tit. 14, div. 6, ch. 3 app H

1. New Appendix H filed 10-8-76; effective thirtieth day thereafter (Register 76, No. 40). NOTE: Order designates that compliance with this appendix is authorized but not mandatory before 1-1-77.
2. Amendment filed 2-2-78; effective thirtieth day thereafter (Register 78, No. 5).

Note: Authority cited: Sections 21083 and 21087, Public Resources Code. Reference: Sections 21000- 21176, Public Resources Code.