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ENVIRONMENTAL IMPACT ASSESSMENT FORM
Receipt No. - ..^ .EIA NO.
Date:
Name of Applicant: M&lfa
Address: ^//7
Permit Applied For:
Case Nos.: ~77P
Location of Proposed Activity:
BACKGROUND INFORMATION
1.-, Give a brief description of the proposed activity (attach
any preliminary development plans).
2. Describe the activity area, including distinguishing
natural and manmade characteristics; also provide precise
slope analysis when appropriate.
3. Describe energy conservation measures incorporated into
the design and/or operation of the project.
ENVIRONMENTAL IMPACT ASSESSMENT FORM
II. Environmental Impact Analysis
Answer the following questions by placing a check in the appropriate
space.
1. Could the project significantly change present land uses
in the vicinity of the activity?
2. Could the activity affect the use of a recreational
area, or area of important aesthetic value?
3. Could the activity affect the functioning of an
established community or neighborhood?
4. Could the activity result in the displacement of
community residents?
5. Are any of the natural or man-made features in the activity
. area unique, that is, not'found in other parts of the
County, State,'or nation? - .
6. .Could the activity significantly affect a historical or
archaelogical site or its setting?
Could the activity significantly affect the potential
use, extraction, or conservation of a scarce natural res-
ource?
8. Does the activity area serve as a habitat, food source
nesting place, source of water, etc. for rare or endangered
wildlife on. fish species?
9. Could the activity significantly affect fish, wildlife or
plant life?
10. Are there any rare or endangered plant species in the
activity .area?
11. Could the activity change existing features of any.of
the city's lagoons, bays, or tidelands?
12. Could the activity change existing features of any of
the City's beaches?
13. Could the activity result in the erosion or elimination
of .agricultural lands? ^
14. Could the activity serve to encourage development of
.presently undeveloped areas or intensify development
of already developed areas?
Yes No
Yes No
15. WiU the activity require a variance from established environmental
standards (air, water, noise, etc)? ;J^ . •
16. Will the activity require certification, authorization or issuance
of a permit by any. local, State or Federal environmental control
agency?
17. Will the activity require issuance of a variance or conditional
use permit by the City?
18. Will the activity involve the application, use, or disposal of
potentially hazardous materials?
19. Will the activity involve construction of facilities in a flood
plain?
20. Will the activity involve construction of facilities on a slope of
: 25 percent or greater? .
21. Will the activity involve construction of facilities in the
area of an active fault?
22. Could the activity result in the generation of significant
amounts of noise? •
23. Could the activity result in the generation of significant
amounts of dust?
24. Will the activity involve the burning of brush, trees, or
other materials? • .
.25. Could the activity result in a significant change in the .
quality of any portion of the region's air or water resources?
(Should note surface, ground water, off-shore).
26. Will there be a significant change to existing land form?
(a) indicate estimated grading to be done in cubic yards, j & i
(b) percentage of alteration to the present land form. ( 0 /Q
(c) maximum height of cut or fill slopes. (a
.27. Will the activity result in substantial increases in the use of utilities, /
sewers, drains or streets? _ ^
III. State of No Significant Environmental Effects
If you have answered yes to one or more of the questions in Section II but you
think the activity will have no significant environmental effects, indicate your
reasons below:
IV: Comments or Elaborations to/^rv
(If additional space is nepded
sheets as may be needed.)
Signature_
Date Signed:..-
of the Questions in Section II.
for answering any, questions, attach additional
completing report)
. Conclusion^ (To be completed by the Planning Director). Place a check
in the appropriate box.
(') Further information is required.
( ) It has been determined that the project will not have significant
environmental effects. ( ) You. must submit a preliminary environmental
impact statement by the following date . . ( ) You
• should make an appointment with the Planning Director to discuss
further processing of your project, in accordance with Chapter 19.04
of the Municipal Code.
DATE RECEIVED:.
BY:-
Planning Director, or.
fcfeyised 7/3/74
FORM PLANNING 40