California Code of Regulations › Title 14 - Natural Resources › Division 6 - Resources Agency › Chapter 3 - Guidelines for Implementation of the California Environmental Quality Act › Appendix H - Environmental Information Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.)
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.