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APPLICANT ENVIRONMENTAL QUESTIONNAIRE

The purpose of this document is to assist AMS staff in collecting adequate project information to complete a detailed 

environmental compliance evaluation. Based on a review of the application submitted, further information is required. 

AMS staff may request further information depending on the information provided by the applicant. 

PROJECT INFORMATION

1. APPLICANT ENTITY NAME AND APPLICATION NO.: 

2. PHYSICAL LOCATION OF THE PROJECT: (INCLUDE GPS COORDINATES AND ADDRESS, LEGAL 

DESCRIPTION AS NECESSARY) 

Please address the questions below and provide a copy of supporting documentation as requested. If you are unsure on 

any of the questions, please select “unknown.”

SURFACE WATERS YES NO UNKNOWN

1 Will any surface water resource (including wetlands, streams, ponds, or 

drainage features) be disturbed, diverted, or otherwise impacted during 

construction or after project completion?

SOILS AND LAND RESOURCES – GROUND DISTURBANCE YES NO UNKNOWN

2 Will the project involve any ground or soil disturbance? ex. 

excavation/bulldozing of soil

2a If yes to 2 above, is the area of ground disturbance known to contain 

contaminated soils?

2b If yes to 2 above, will the project install, remove, or replace any 

underground storage tanks?

2c If yes to 2 above, has this soil been previously 

disturbed/altered/excavated? 

VEGETATION YES NO UNKNOWN

3 Will the project remove or alter existing vegetation or trees at the site? If 

yes, please provide detail on the kind and amount (ac./sq.ft.) of vegetation 

that will be removed in the box on page 3.
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CULTURAL RESOURCES (HISTORIC, ARCHAEOLOGICAL, TRIBAL) YES NO UNKNOWN 

4 Will the project be located in/on a building that is more than 50 years old?

*local tax records usually indicate the date or year a building was 

constructed. If you are unsure of a building’s age, please check with your 

assessor’s office

5 Will the project be located within sight of a building that is more than 50 

years old? 

WATER QUALITY YES NO UNKNOWN

6 Will wastewater (e.g., sanitary sewage, non-contact cooling water, slurries, 

dewatering, etc.) be generated during the project and/or after the project 

is complete for release offsite?

7 Is the project facility connected to a municipal wastewater system? If not, 

describe the on-site system and capacity in the box on page 3.

8 Is the project facility connected to a municipal water supply system? If 

not, describe the on-site system and capacity in the box on page 3.

9 Will National Pollutant Discharge Elimination Systems (NPDES) or Clean 

Water Act Permits be required or currently applicable? 

SOCIOECONOMIC/ENVIRONMENTAL JUSTICE YES NO UNKNOWN

10 Does the project have the potential to negatively impact the human health 

or environment of disadvantaged populations, low-income populations, 

and/or Indian tribes and Indigenous communities?

AIR QUALITY/CLIMATE CHANGE YES NO UNKNOWN

11 Will air emission-generating equipment be installed or replaced 

(generators, boilers, fuel burning equipment, or refrigerant containing 

equipment, etc.)? If so, provide details or specifications in the box on page 

3.

12 Will the project cause any known increase in air pollutants (carbon 

dioxide, greenhouse gases) during project upgrades or operation?

HAZARDOUS MATERIALS/WASTE OR TOXIC SUBSTANCES YES NO UNKNOWN

13 Will the project result in the disturbance of lead- or asbestos-containing 

materials?

14 Will the project result in the use, storage, or disposal of hazardous 

materials?

15 Will the project involve pesticide application (e.g., herbicide or 

insecticide)?

16 Will the project remove, install, or utilize an aboveground or underground 

oil or petroleum storage container that is equal to or greater than 55 

gallons (e.g., fixed or portable storage tanks, drums, base tanks for 

emergency generators, cooking oil containers, or hydraulic reservoirs)? 

LAND USE AND UTILITIES YES NO UNKNOWN

17 Will the project result in an increase in utility use (e.g., natural gas, 

electricity, water, sewer)? Provide any applicable capacity information or 

specifications in the box on page 3.

18 Will the project result in a change in activities, land use, or zoning 

occurring at the site or facility?

19 Will the project cause long-term noise impacts to the area or impacts 

outside of the allowable times as regulated by local ordinances?

20 Would the project alter or obstruct views or aesthetics in the immediate 

vicinity of the site?
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PLEASE PROVIDE ADDITIONAL PROJECT INFORMATION: PERMIT REQUIREMENTS, PREVIOUS 

CONSULTATIONS, ENVIRONMENTAL CONCERNS AND/OR FURTHER EXPLANATIONS TO RESPONSES 

ABOVE.

Questions are answered to the best of the applicants’ ability. Applicant understands AMS may conduct additional screenings and 

review of findings will determine any further requirements. AMS reserves the right to deny an application that has the potential for 

significant environmental impacts, cannot obtain proper permitting, does not meet NEPA or permitting policies or does not provide 

required documentation.

Name and Title of Preparer/Applicant Date