DORMITORY AUTHORITY — STATE of NEW YORK
OFFICE of ENVIRONMENTAL AFFAIRS

Short Environmental Assessment Form - Part I

617.20
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only

1. Application sponsor________________________________________________________________

2. Project name_____________________________________________________________________

3. Project location:

Municipality___________________________________________ County________________________

4. Precise location: (Street address and road intersections, prominent landmarks, etc., or provide map)
__________________________________________________________________________________
__________________________________________________________________________________

5. Is Proposed Action:

New
Expansion
Modification/alteration

6. Describe project briefly:
__________________________________________________________________________________
__________________________________________________________________________________

7. Amount of Land Affected: Initially___ ___Acres Ultimately___ ___Acres

8. Will prorposed action comply with existing zoning or other existing land use restrictions?
Yes
No (If no, describe briefly)

9. What is present land use in vicinity of project?
Residential
Industrial
Commercial
Agriculture
Park/Forest/Open space
Other (Describe:)

10. Does action involve a permit approval, or funding, now or ultimately from any other governmental agency (Federal, State or Local)?
Yes
No (If yes, list agency(s) and permit/approval)

11. Does any aspect of the action have a currently valid permit or approval?
Yes
No (If yes, list agency name and permit/approval)

12. As a result of proposed action will existing permit/approval require modification?
Yes
No

I certify that the information provided above is true to the best of my knowledge

Applicant/sponsor name:_____________________________________________ Date:_____________________

Print Name/Title:________________________________________________

Signature:_____________________________________________________

DORMITORY AUTHORITY — STATE of NEW YORK OFFICE of ENVIRONMENTAL AFFAIRS

Short Environmental Assessment Form - Part I

617.20 Appendix C State Environmental Quality Review SHORT ENVIRONMENTAL ASSESSMENT FORM For UNLISTED ACTIONS Only

DORMITORY AUTHORITY — STATE of NEW YORK
OFFICE of ENVIRONMENTAL AFFAIRS

617.20
Appendix C
State Environmental Quality Review
SHORT ENVIRONMENTAL ASSESSMENT FORM
For UNLISTED ACTIONS Only