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| O |                 |   |       | Date:         | Program:           |
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|   |                 |   |       |               |                    |
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| h |                 |   |       |               |                    |
| o |                 |   |       |               |                    |
| t |                 |   |       |               |                    |
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| s |                 |   |       |               |                    |
|   |                 |   |       |               |                    |
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|   |                 |   |       |               |                    |
| d |                 |   |       |               |                    |
| i |                 |   |       |               |                    |
| a |                 |   |       |               |                    |
| g |                 |   |       |               |                    |
| r |                 |   |       |               |                    |
| a |                 |   |       |               |                    |
| m |                 |   |       |               |                    |
| s |                 |   |       |               |                    |
|   |                 |   |       |               |                    |
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| s |                 |   |       |               |                    |
|   |                 |   |       |               |                    |
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|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| # | **RESOURCE      |   | ## EF |               |                    |
| # | CONDITION**     |   | FECTS |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| # | **SOILS:**      |   |       |               |                    |
| # |                 |   |       |               |                    |
|   |                 |   |       |               |                    |
| I |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| a | Natural soil    |   | Not   |               |                    |
| \ | surface         |   | Appli |               |                    |
| . | (altering soil  |   | cable |               |                    |
|   | struc\--ture,   |   | No    |               |                    |
|   | soil            |   | e     |               |                    |
|   | displacem       |   | ffect |               |                    |
|   | ent/deposition, |   |       |               |                    |
|   | compaction,     |   | Stat  |               |                    |
|   | organic matter) |   | ement |               |                    |
|   |                 |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| b | Soil Fertility  |   | Not   |               |                    |
| \ |                 |   | Appli |               |                    |
| . |                 |   | cable |               |                    |
|   |                 |   | No    |               |                    |
|   |                 |   | e     |               |                    |
|   |                 |   | ffect |               |                    |
|   |                 |   |       |               |                    |
|   |                 |   | Stat  |               |                    |
|   |                 |   | ement |               |                    |
|   |                 |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| c | Unique geologic |   | Not   |               |                    |
| \ | or natural      |   | Appli |               |                    |
| . | physical        |   | cable |               |                    |
|   | features ( e.g. |   | No    |               |                    |
|   | covering,       |   | e     |               |                    |
|   | modification,   |   | ffect |               |                    |
|   | partial         |   |       |               |                    |
|   | destruction,    |   | Stat  |               |                    |
|   | protection,     |   | ement |               |                    |
|   | etc.)           |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| d | Wind or water   |   | Not   |               |                    |
| \ | erosion of      |   | Appli |               |                    |
| . | soils, or soil  |   | cable |               |                    |
|   | erodibility     |   | No    |               |                    |
|   |                 |   | e     |               |                    |
|   |                 |   | ffect |               |                    |
|   |                 |   |       |               |                    |
|   |                 |   | Stat  |               |                    |
|   |                 |   | ement |               |                    |
|   |                 |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| e | Siltation,      |   | Not   |               |                    |
| \ | deposition, or  |   | Appli |               |                    |
| . | erosion that    |   | cable |               |                    |
|   | may impact or   |   | No    |               |                    |
|   | modify a        |   | e     |               |                    |
|   | stream, river   |   | ffect |               |                    |
|   | channel,        |   |       |               |                    |
|   | lakebed, or     |   | Stat  |               |                    |
|   | other waterbody |   | ement |               |                    |
|   |                 |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| f | Exposure of     |   | Not   |               |                    |
| \ | people or       |   | Appli |               |                    |
| . | property to     |   | cable |               |                    |
|   | geologic        |   | No    |               |                    |
|   | hazards         |   | e     |               |                    |
|   |                 |   | ffect |               |                    |
|   |                 |   |       |               |                    |
|   |                 |   | Stat  |               |                    |
|   |                 |   | ement |               |                    |
|   |                 |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+
| g | Acres of Prime  |   | Not   |               |                    |
|   | or unique       |   | Appli |               |                    |
|   | farmland        |   | cable |               |                    |
|   |                 |   | No    |               |                    |
|   |                 |   | e     |               |                    |
|   |                 |   | ffect |               |                    |
|   |                 |   |       |               |                    |
|   |                 |   | Stat  |               |                    |
|   |                 |   | ement |               |                    |
|   |                 |   | of    |               |                    |
|   |                 |   | Ef    |               |                    |
|   |                 |   | fect: |               |                    |
|   |                 |   |       |               |                    |
+---+-----------------+---+-------+---------------+--------------------+

+---+-----------------+---+--------+---------+-------------------------+
| # | ## RES          |   | ## E   |         |                         |
| # | OURCE CONDITION |   | FFECTS |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| # | **WATER:**      |   |        |         |                         |
| # |                 |   |        |         |                         |
|   |                 |   |        |         |                         |
| I |                 |   |        |         |                         |
| I |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| a | Stream channel  |   | Not    |         |                         |
| \ | dimension,      |   | Appl   |         |                         |
| . | pattern, and/or |   | icable |         |                         |
|   | slope           |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| b | Surface water   |   | Not    |         |                         |
| \ | infiltration    |   | Appl   |         |                         |
| . | rates, drainage |   | icable |         |                         |
|   | patterns,       |   | No     |         |                         |
|   | velocities,     |   | effect |         |                         |
|   | and/or volumes  |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| c | Discharge into  |   | Not    |         |                         |
| \ | surface waters, |   | Appl   |         |                         |
| . | alterations of  |   | icable |         |                         |
|   | surface water   |   | No     |         |                         |
|   | quality         |   | effect |         |                         |
|   | (temperature &  |   |        |         |                         |
|   | turbidity)      |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| d | Wetland         |   | Not    |         |                         |
| \ | hydrology       |   | Appl   |         |                         |
| . |                 |   | icable |         |                         |
|   |                 |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| e | Ground water    |   | Not    |         |                         |
| \ | quantity        |   | Appl   |         |                         |
| . |                 |   | icable |         |                         |
|   |                 |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| f | Ground water    |   | Not    |         |                         |
| \ | quality         |   | Appl   |         |                         |
| . |                 |   | icable |         |                         |
|   |                 |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| g | Amount of water |   | Not    |         |                         |
| \ | available for   |   | Appl   |         |                         |
| . | public use      |   | icable |         |                         |
|   |                 |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| h | Wild & Scenic   |   | Not    |         |                         |
| \ | rivers or       |   | Appl   |         |                         |
| . | unique waters   |   | icable |         |                         |
|   |                 |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| i | Floodplains or  |   | Not    |         |                         |
| \ | floodplain      |   | Appl   |         |                         |
| . | management      |   | icable |         |                         |
|   |                 |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| # | Exposure of     |   | Not    |         |                         |
|   | people or       |   | Appl   |         |                         |
| j | property to     |   | icable |         |                         |
| . | flooding        |   | No     |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   |        |         |                         |
|   |                 |   | Sta    |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | of     |         |                         |
|   |                 |   | E      |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| * | **AIR:**        |   |        |         |                         |
| * |                 |   |        |         |                         |
| I |                 |   |        |         |                         |
| I |                 |   |        |         |                         |
| I |                 |   |        |         |                         |
| * |                 |   |        |         |                         |
| * |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| a | > Impacts to    |   | > Not  |         |                         |
| \ | > air quality,  |   | > Appl |         |                         |
| . | > including     |   | icable |         |                         |
|   | > dust, odors   |   | > No   |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   | > Sta  |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| b | > Impacts to    |   | > Not  |         |                         |
| \ | > air quality,  |   | > Appl |         |                         |
| . | > PM-10 and     |   | icable |         |                         |
|   | > PM-2.5        |   | > No   |         |                         |
|   | >               |   | >      |         |                         |
|   |  non-attainment |   | effect |         |                         |
|   | > areas         |   | >      |         |                         |
|   |                 |   | > Sta  |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| c | > Impacts to    |   | > Not  |         |                         |
| \ | > other air     |   | > Appl |         |                         |
| . | > quality       |   | icable |         |                         |
|   | > factors       |   | > No   |         |                         |
|   | >               |   | >      |         |                         |
|   | > (chemical     |   | effect |         |                         |
|   | > drift,        |   | >      |         |                         |
|   | > visibility,   |   | > Sta  |         |                         |
|   | > smoke)        |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| # | > **PLANTS:**   |   |        |         |                         |
| # |                 |   |        |         |                         |
|   |                 |   |        |         |                         |
| I |                 |   |        |         |                         |
| V |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| a | > Diversity or  |   | > Not  |         |                         |
| \ | > abundance of  |   | > Appl |         |                         |
| . | > any species,  |   | icable |         |                         |
|   | > including     |   | > No   |         |                         |
|   | > sensitive     |   | >      |         |                         |
|   | > species       |   | effect |         |                         |
|   | > recognized by |   | >      |         |                         |
|   | > BLM, FS, or   |   | > Sta  |         |                         |
|   | > Tribes and    |   | tement |         |                         |
|   | > those         |   | > of   |         |                         |
|   | > protected by  |   | > E    |         |                         |
|   | > Arizona       |   | ffect: |         |                         |
|   | > Native Plant  |   | >      |         |                         |
|   | > Law           |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| b | > Threatened,   |   | > Not  |         |                         |
| \ | > Endangered,   |   | > Appl |         |                         |
| . | > Proposed or   |   | icable |         |                         |
|   | > Candidate     |   | > No   |         |                         |
|   | > Species       |   | >      |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   | > Sta  |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| c | > Critical      |   | > Not  |         |                         |
|   | > Habitat,      |   | > Appl |         |                         |
|   | > Proposed      |   | icable |         |                         |
|   | > Critical      |   | > No   |         |                         |
|   | > Habitat       |   | >      |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   | > Sta  |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| c | > Regeneration  |   | > Not  |         |                         |
| \ | > of native     |   | > Appl |         |                         |
| . | > species       |   | icable |         |                         |
|   |                 |   | > No   |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   | effect |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   | > Sta  |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| e | > Opportunity   |   | > Not  |         |                         |
| \ | > for noxious   |   | > Appl |         |                         |
| . | > weeds and/or  |   | icable |         |                         |
|   | > invasive      |   | > No   |         |                         |
|   | > species to    |   | >      |         |                         |
|   | > become        |   | effect |         |                         |
|   | > established   |   | >      |         |                         |
|   | > or spread     |   | > Sta  |         |                         |
|   |                 |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+
| f | > Functional    |   | > Not  |         |                         |
| \ | > groups        |   | > Appl |         |                         |
| . | > (warm-cool    |   | icable |         |                         |
|   | > season)       |   | > No   |         |                         |
|   | >               |   | >      |         |                         |
|   | > Or Structural |   | effect |         |                         |
|   | > groups        |   | >      |         |                         |
|   | > (gr           |   | > Sta  |         |                         |
|   | ass-shrub-tree) |   | tement |         |                         |
|   |                 |   | > of   |         |                         |
|   |                 |   | > E    |         |                         |
|   |                 |   | ffect: |         |                         |
|   |                 |   | >      |         |                         |
|   |                 |   |        |         |                         |
+---+-----------------+---+--------+---------+-------------------------+

+---+-------------------+---------------------------------------------+
| # | ## R              | ## EFFECTS                                  |
| # | ESOURCE CONDITION |                                             |
|   |                   |                                             |
+---+-------------------+---------------------------------------------+
| # | > **ANIMALS:**    |                                             |
| # |                   |                                             |
|   |                   |                                             |
| V |                   |                                             |
+---+-------------------+---------------------------------------------+
| a | > Diversity or    | > Not Applicable No effect                  |
| \ | > abundance of    | >                                           |
| . | > any species,    | > Statement of Effect:                      |
|   | > including       |                                             |
|   | > sensitive       |                                             |
|   | > species         |                                             |
|   | > recognized by   |                                             |
|   | > BLM, FS, or     |                                             |
|   | > Tribes          |                                             |
+---+-------------------+---------------------------------------------+
| b | > Threatened,     | > Not Applicable No effect                  |
| \ | > Endangered,     | >                                           |
| . | > Proposed or     | > Statement of Effect:                      |
|   | > Candidate       |                                             |
|   | > Species         |                                             |
+---+-------------------+---------------------------------------------+
| c | > Critical        | > Not Applicable No effect                  |
|   | > Habitat,        | >                                           |
|   | > Proposed        | > Statement of Effect:                      |
|   | > Critical        |                                             |
|   | > Habitat         |                                             |
+---+-------------------+---------------------------------------------+
| d | > Indigenous      | > Not Applicable No effect                  |
| \ | > animals         | >                                           |
| . | > (migration      | > Statement of Effect:                      |
|   | > barriers,       |                                             |
|   | > competition     |                                             |
|   | > from            |                                             |
|   | > non-natives)    |                                             |
+---+-------------------+---------------------------------------------+
| e | > Habitat         | > Not Applicable No effect                  |
| \ | >                 | >                                           |
| . | > (nesting,       | > Statement of Effect:                      |
|   | > calving,        |                                             |
|   | > wintering,      |                                             |
|   | > spawning)       |                                             |
+---+-------------------+---------------------------------------------+
| f | > Human activity  | > Not Applicable No effect                  |
| \ | > during          | >                                           |
| . | > sensitive life  | > Statement of Effect:                      |
|   | > stages          |                                             |
|   | > (nesting,       |                                             |
|   | > spawning,       |                                             |
|   | > hibernating)    |                                             |
+---+-------------------+---------------------------------------------+
| * | > **CULTURAL      |                                             |
| * | > RESOURCES:**    |                                             |
| V |                   |                                             |
| I |                   |                                             |
| * |                   |                                             |
| * |                   |                                             |
+---+-------------------+---------------------------------------------+
| a | > Prehistoric or  | > Not Applicable No effect                  |
| \ | > historical      | >                                           |
| . | > archaeological  | > Statement of Effect:                      |
|   | > sites           |                                             |
+---+-------------------+---------------------------------------------+
| b | > Prehistoric or  | > Not Applicable No effect                  |
| \ | > historical      | >                                           |
| . | > structures      | > Statement of Effect:                      |
+---+-------------------+---------------------------------------------+
| c | > Prehistoric or  | > Not Applicable No effect                  |
| \ | > historical-era  | >                                           |
| . | > isolated        | > Statement of Effect:                      |
|   | > objects         |                                             |
+---+-------------------+---------------------------------------------+
| d | > Known sacred    | > Not Applicable No effect                  |
| \ | > uses or         | >                                           |
| . | > traditional     | > Statement of Effect:                      |
|   | > cultural places |                                             |
|   | > within or       |                                             |
|   | > adjacent to the |                                             |
|   | > area of         |                                             |
|   | > potential       |                                             |
|   | > impact          |                                             |
+---+-------------------+---------------------------------------------+
| # | > OTHER HUMAN     |                                             |
| # | > CONSIDERATONS:  |                                             |
|   | >                 |                                             |
| V | > **Include       |                                             |
| I | > Environmental   |                                             |
| I | > Justice         |                                             |
|   | > concerns in     |                                             |
|   | > assessment and  |                                             |
|   | > remarks**       |                                             |
+---+-------------------+---------------------------------------------+
| a | > Existing noise  | > Not Applicable No effect                  |
| \ | > levels          | >                                           |
| . |                   | > Statement of Effect:                      |
+---+-------------------+---------------------------------------------+
| b | > Present or      | > Not Applicable No effect                  |
| \ | > planned land    | >                                           |
| . | > uses            | > Statement of Effect:                      |
+---+-------------------+---------------------------------------------+
| c | > Landscape       | > Not Applicable No effect                  |
| \ | > resource,       | >                                           |
| . | > aesthetic       | > Statement of Effect:                      |
|   | > resource,       |                                             |
|   | > scenic value,   |                                             |
|   | > or natural area |                                             |
+---+-------------------+---------------------------------------------+
| d | > Recreational    | > Not Applicable No effect                  |
| \ | > opportunities   | >                                           |
| . |                   | > Statement of Effect:                      |
+---+-------------------+---------------------------------------------+
| e | > Public health   | > Not Applicable No effect                  |
| \ | > and safety      | >                                           |
| . |                   | > Statement of Effect:                      |
+---+-------------------+---------------------------------------------+
| f | > Public interest | > Not Applicable No effect                  |
| \ | > or controversy  | >                                           |
| . |                   | > Statement of Effect:                      |
+---+-------------------+---------------------------------------------+
| g | > Significant     | > Not Applicable No effect                  |
| \ | > economic        | >                                           |
| . | > impacts to the  | > Statement of Effect:                      |
|   | > sponsor,        |                                             |
|   | >                 |                                             |
|   | > Landowners, or  |                                             |
|   | > public          |                                             |
+---+-------------------+---------------------------------------------+

+-----------------------------------------------------------------------+
| **OTHER CONSIDERATIONS:**                                             |
+-----------------------------------------------------------------------+
| Is a Water Quality 401 & Army Corps of Engineers 404 permit required? |
| Yes No                                                                |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+
| If required who will prepare?                                         |
+-----------------------------------------------------------------------+
| Other state, county, tribal, & local requirements and/or permits      |
| needed:                                                               |
+-----------------------------------------------------------------------+
| List any permits or items needing attention.                          |
+-----------------------------------------------------------------------+
| Any mitigation planned or required?                                   |
+-----------------------------------------------------------------------+
| **Document communications (as appropriate) with:**                    |
+-----------------------------------------------------------------------+
| Cultural Resource Specialist (NRCS, SHPO, Indian Nation, BIA):        |
+-----------------------------------------------------------------------+
| ASLD, AGFD, FWS, FS, BLM, COE, ADEQ, ADWR, Indian Nation Natural      |
| Resource Department:                                                  |
+-----------------------------------------------------------------------+
| Discuss any cumulative effects (beneficial or adverse) on resource    |
| conditions, or any applicable cumulative effects analysis:            |
+-----------------------------------------------------------------------+
| **Comments or other considerations**:                                 |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

**RECOMMENDATION** (check one):

\_\_\_\_\_Proceed with action. No further environmental analysis is
necessary.

\_\_\_\_\_Further analysis is recommended. A Biological Assessment,
Environmental Assessment, or Environmental Impact Statement may be
necessary.

\_\_\_\_\_Do not proceed. Significant adverse effects will result. Other
alternatives will be explored.

### CERTIFICATION

           

Preparer's Signature Title Date

           

Reviewed/Concurred Title Date

### 

### Policy References:

  ------------------------------- ---------------------------------------
                                  

  Concerns**-**See \"Help         Field Office Technical Guide
  Sheets\"                        

  Prime and Unique Farmland       310 GM 403

  Threatened or Endangered        190 GM 410.22(b)
  Species                         

  Landscape Resource              190 GM 410.24

  Invasive Species                Executive Order 13112

  Coastal Zone Management Area    NRCS/ASCS/EXT 3/9/93 Letter

  Natural Area                    190 GM 410.23

  Wild and Scenic Rivers          FOTG Section 1

  Wetland                         190 GM 410.26 FSA Manual & COE Tech Rpt
                                  Y-87-1

  Riparian Area                   190 GM 411

  Special Aquatic Site            EPA 404(b)(1)230.3 & 230.10, Federal
                                  Register 12/24/80

  Floodplain Management           190 GM 410.25, Executive Order 11988

  Stream Channel Modification     190 GM 410.27

  Cultural Resources              420 GM 401,601

  Environmental Justice           Executive Order 12898 and USDA
                                  Regulation 5600-2
  ------------------------------- ---------------------------------------