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
(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.
