HomeMy WebLinkAboutSEPA EPIC-FD-101 - DENNY'S - 5,390 SF RESTAURANTDENNY'S
13100 48 ' AVE S
EPIC-FD-101
CITY OF TUKWILA
OFFICE OF COMMUNITY DEVELOPMENT
111111.111/FINAL
DECLARATION OF 'JON - SIGNIFICANCE
Description of proposal Restaurant - 5,390 sq. ft.
Proponent
Denny's, Inc.
South side of 48th Avenue South - 330 feet East of
Location of Proposal Interurban Avenue
Lead Agency City of Tukwila /Building Division
File No EPIC -FD -101
This proposal has been determined to (/not have) a significant adverse im-
pact upon the environment. An EIS (II/is not) required under RCW 43.210.030(2)
(c). This decision was made after review by the lead agency of a completed
environmental checklist and other information on file with the lead agency.
Responsible Official .Fred Satterstrom
Position /Title
Associate Planner
Date 24 May 1979 Signature G frat,N
COMMENTS:
I fir 1W 45/0 kPuS
This Declaration of Non - Significance is conditioned on the applicant
completing the following stipulations as part of the total project:
1. A five (5) foot wide sidewalk shall be constructed along 48th Avenue
South as shown on the site plan. Detailed plans to be approved by
the Department of Public Works under issuance of a Street Use Permit.
2. The landscaping along the freeway is to be modified to create year -
round site screening by replacing the proposed Norway Maples with
evergreen trees such as Scotish Pines or Douglas Fir on a maximum of
thirty (30) foot centers.
'To be sent in duplicate; one. copy returned to Building Dept;, 2nd copy for your file.)
Public Works Department- DATE
Planning Department
Fire Department
TO:
X�
FROM: Building Department
SUBJECT:
Dennys •
(Omer)
.0ctober 30, 1979
Permit No. 1735
1.3100. 48th Ave. So. Tyke Business Restaurant
(Address)
The subject project is nearingcompletion. Please investigate your area of
respon_sibil i ty and indicate below either your acceptance or corrections
necessary in order that a Certificate of Occupancy .may be issued.
IF NO RESPONSE IS RECEIVED WITHIN 7 DAYS, IT IS ASSUMED THAT 'THE "MATTER
IS NOT OF CONCERN TO YOUR DEPARTMjNT AND r•Pa T T FT f t cc r
r
TO: Building Department
14I(K - PI,n.N1.111.16,
This project is approved by this department subject to the folloi;,ng corrections
WtTNOLD o . . UK) T1L G00,1 T O) Z. OF , Tut . arr�cM SD
Ode. -a J11oJ of ►Joy- SI4mtricnrice, is s.6..,,c,r -ice iu T14 E
BUI.LOU \JG DEPT
433 -- 1 8 49
.6200 S outhcenter
Btvd
9 8'188
;,horized Signature
des by
ci d by
project title
dat e
CITY OF TUKWILA
ENV I `dMENTAL QUESTIONNAIRE RE MI FORM
PROJECT NAME:
PROJECT ADDRESS:
`77euNys 5-
0_
DATE ACCEPTED FOR FILING:
1. DEPARTME TAL REVIEW: (date) (reviewer)
Building: ',71,0c4 /D, / q 2, / by: a .e.Aje.
C3 9
Engineering: J by:
❑ Fire: by:
❑ Planning: by:
C3 Police: by:
2. ANY PERTINENT COMMENTS:
C OZ1 /itom// 3
CITY OF TUKWILA
ENV.I ku,' NEUTAL OUEST I O' IRE RE AP FORM
PROJECT NAME: BNiv ¶S' CiQ votoawl
PROJECT ADDRESS: 48 /ve. Sot—fit
DATE ACCEPTED FOR FILING: 5/9//7,
1. DEPARTMENTAL REVIEW: (date) (reviewer)
❑ Building: by:
E Engineering: 474 / by:
C3 Fire: / by:
❑ Planning: by:
❑.Police: by:
2. ANY PERTINENT COMMENTS,:
CITY OF TUKWILA
ENVIRONMENTAL CHECKLIST FORM
This questionnaire must be completed and submitted with the application for
permit. This questionnaire must be completed by all persons applying for a
permit from the City of Tukwila, unless it is determined by the Responsible
Official that the permit is exempt or unless the applicant and Responsible
Official previously agree an Environmental Impact Statement needs to be completed.
A fee of $50.00 must accompany the filling of the Environmental Questionnaire
to cover costs of the threshold determination.
I. BACKGROUND
1. . Name of Proponent: • <.b Zarr, T �url J
2 . Address and Phone Number of Proponent: / p% n e t 4'442,5":45-5 33 72
%J' 1 d j, My? P 6: T4(5%157
3. Date Checklist Submitted: MAY- 1-/.779.
4. Agency Requiring Checklist: C; i3/ o ?" 74,Ll,1 /ch
5. Name of Proposal, if applicable : /jOenryS ‘5-72es7aczrar7 %/i5Z
6. Nature and Brief Description of the Proposal (including but not limited
to its size, general design elements, and other factors that will give
an accurate understanding of its scope and nature):
AStir % 1574 r e57a u' a'7 ` Corm'% /1:4 5e 7
r e, �" - r r! 5
(describe the physical settin of the proposal, as
7. Location of Proposal {des p y setting
.of
as the extent of the land area affected by any environmental im-
pacts, including any 'other information needed to give an accurate under-
standing of the environmental setting of the proposal):.
�occ7 �?Gr/ G✓.`cfe ' 4/� �� I T1 ✓�°' �JO . �i��ro,l�. J �/4 �!
aS7ePly -12-o n ra. r6ar7 ride. o:�•i/5 rl
t <-'5 7 1 ,'n /1 b' Se •-r/� cc S f 'o r� �
8. Estimated Date for Completion of the Proposal: ebr'&€ r,/ --//290
9. List of all Permits, Licenses or Government-Approvals Required for the
Proposal (federal, state and local):
(a) Rezone, conditional use, shoreline permit, etc. YES NOX
(h) King County Hydraulics Permit YES)< NO
(c) Building permit YES( NO ___
rl
(d) Puget Sound Air Pollution Control Permit YES NO
(e) Sewer hook up permit YES \ NO.
(f) Sign permit YES )( NO
(g) Water hook up permit YES )4 NO
(h) Storm water system permit YES X NO
(i) Curb cut permit YES ) NO
(j) Electrical permit (State of Washington) YES 7‹ NO _
(k) Plumbing permit (King County) 1 USX NO
(1) Other: ; i� Coa 77y iea /i 4 .rep'7
S �e Lror Scca r a ,
10. Do you have any plans for future additions, expansion, or futher activity
related to or connected with this proposal? If yes, explain:
11. Do you know of any plans by others which may affect the property covered by
your proposal? If yes, explain:
/Vo
12. Attach any other application form that has been completed regarding the pro-
posal; if none has been completed, but is expected to be filed at some future
date, describe the nature of such application form:
/Yo r e v h e � 7L%/7 1's � //7 # %, o,% ,
II. ENVIRONMENTAL IMPACTS
(Explanations of all "yes" and "maybe" answers are required) .
1. Earth. Will the proposal result in:
(a) Unstable earth conditions or in changes in geologic
substructures?
(b) Disruptions, displacements, compaction or_overcoyer-
ing of the soil?
(c) Change in topography or ground surface relief fea-
tures?
(d) The destruction, covering or modification of any
unique geologic or physical features?
YES MAYBE NO
(e) Any increase in wind or water erosion of soils,
either on or off the site?
Changes in deposition or erosion of beach sands, or
changes in siltation, deposition or erosion which
may modify the channel of a river or stream or the
bed of the ocean or any bay, inlet or lake?
(f)
Explanation:
2. Air. Will the proposal result in:
(a) Air emissions or deterioration of ambient air
quality?
(b) The creation of objectionable odors? 4-)4A‘m\
(c) Alteration of air movement, moisture
or temperature, or any change in climate, either \ ,
locally or regionally? �C
YES MAYBE NO
X
Explanation:
All ,77/5 5, ,15 i // 'e
f/1 e d �%1�c ;J ,1 Sy s7/,7
Pre vf.ea s +pre 'e� 0,/ ' ' C4' •
-Yeafth �719ee• d
3. Water. Will the proposal result in:
(a) Changes in currents, o,r the course or direction
of water movements, in either marine or fresh
waters?
(b) Changes in absorption rates, drainage patterns,
or the rate and amount. of surface water runoff?
(c) Alterations to the course or flow of flood waters?
(d) Change in the amount of surface water in any water
body?
(e) Discharge into surface waters, or in any alteration
of surface water quality, including but not limited
to temperature, dissolved oxygen or turbi di t 4,,,,
(f) Alteration of the direction or rate of flow of
ground waters?
(g) Change in the quantity of ground waters, either
through direct additions or withdrawals, or through
interception of an aquifer by cuts or excavations?
-3-
b'tr
7(
X
• •
(h) Deterioration in ground water quality, either
through direct injection, or through the seepage
of leachate, phosphates, detergents, waterborne
virus or bacteria, or other substances into the
ground waters?
(i) Reduction in the amount of water otherwise avail -
able for public water supplies?
Explanation:
flo✓i9i0.7 9 o/ /c? '- �f r
W/r COP7 y M , � c00„4
i_fy ,/ra.u1 ;c5
YES rAYBE NO
4. Flora. Will the proposal result in:
(a) Change in the diversity of species, or numbers
of any species of flora (including trees, shrubs,
grass, crops, microflora and aquatic plants)? _
(b) Reduction of the numbers of any unique, rare or
endangered species of flora? !,
(c) Introduction of new species of flora into an area,
or in a barrier to the normal replenishment of
existing species? —
(d) Reduction in acreage of any agricultural crop? /
Explanation: Ja ft capJn ,4roc<4 7 e Sa,h
� si •e /43 WY/ � �n�ro ✓C Ali, j c
�5 awe Xca.71,
5. Fauna.. Will the proposal result in:
(a) Changes in the diversity of species, or numbers
of any species of fauna (birds, land animals
including reptiles, fish and shellfish, benthic
organisms, insects or microfauna)?
(b) Reduction of the numbers of any unique, rare or
endangered species of fauna?
(c) Introduction of new species of fauna into an
area, or result in a barrier to the migration
or movement of fauna?
(d) Deterioration to existing . fish or wildlife
habitat?
Explanation:
4
•:
6. Noise. Will the proposal increase existing noise
levels?
Explanation: '"'``°
7. Light and Glare. Will the proposal produce new
light or glare?
Explanation: far-k,,70, Lo7�' G��`' v'/// 34c
,'i-eG fe4 dofc er7 g7Lei kV /7 //7
-2:7e/7/7/5 P'ofer7y.
8. Land Use. Will the proposal result in the altera-
.tion of the present or planned land use
of an area?
Explanation: j 71e
7pfl? " /7WWf .
9. Natural Resources. Will-the proposal result in:
(a) Increase in the rate of use of any natural
resources?
(b) Depletion of any nonrenewable natural
resource?
Explanation:
10. Risk of Upset. Does the proposal involve a risk of an
explosion or the release of hazardous
substances (including, but not limited
to, oil, pesticides, chemicals or radi-
ation) in the event of an accident or
upset conditions?
Explanation:
YES MWE NO
7?-<-
• •
11. Population. Will the proposal alter the location,
distribution, density, or growth rate
of the human population of an arc,.;?
Explanation:
12. Housing. Will the proposal affect existing housing,
or create a demand for additional housing?
Explanation:
13. Transportation /Circulation. Will the proposal result in:
(a) Generation of additional vehicular movement?
(b) Effects on existing parking facilities, or
demand for new parking?
(c) Impact upon existing transportation systems?
(d) Alterations to present patterns of circulation
or movement of people and /or goods? *ANL
(e) Alterations to waterborne, rail or air traffic?
YES t;".'Er)
tekrei_.°
)4
(f) Increase in traffic hazards to motor vehicles,
bicyclists or pedestrians? 1-"- %C
Explanation: 0/7- 5;71. Prf;.:n W' /% 8� �r'o ✓, -�c� /
�e ua7e �Gcor7,'dcr fe �%ronS 4% /c 5 .
14 Public Services. Will the proposal have an effect upon,
or result in a need for new or altered
governmental services' in any of the
following areas:
(a) Fire protection?
(b) Police protection?
(c) Schools?
(d) Parks or other recreational facilities?
(e) Maintenance of public facilities, including
roads?
(f)
Other governmental services?
YES MAYBE NO
Explanation: -7—M5 W./ Tye ,1 �fi're -774_,: 0/fr.
4�� 77�
41 f �e ede,7 f o 1 G��c•�i 7e47 '
15. Energy. Will the proposal result in:
(a) Use of substantial amounts of fuel or energy?
(b) Demand upon existing sources of energy, or
require the development of new sources of
energy?
Explanation:
16. Utilities. Will the proposal result in a need for
new systems, or alterations to the
following utilities:
(a) Power or natural gas?
(b) Communications systems?
(c) Water?
(d) Sewer
(e) Storm water drainage
(f) Solid waste and disposal?
Explanation :. 4// L./ /' /e 5 �.e �d�r,-//
gth /e
fi;/- U° ' Mi/re < .'O?7,
17: Human Health. Will the proposal result in the crea-
tion of any health hazard or potential
health hazard (excluding mental health)?
Explanation:
18. Aesthetics. Will the proposal result in the obstruc-
tion of any scenic vista or view open to
the public, or will the proposal result
in the creation of an aesthetically of-
fensive site open to public view?
Explanation:
19. Recreation. Will the proposal result in an impact
upon the quality or quantity of exist-
ing recreational opportunities?
Explanation:
20. Archeological /Histroical. Will the proposal result in
an alteration of a signifi-
cant archeological or his-
torical site, structure,
object or building?
Explanation:
YES MAYBE ro
CERTIFICATION BY APPLICANT:
I, the undersigned, state that to the best of my knowledge the above
information is true and complete. It is understood that the lead agency
may withdraw any declaration of non - significance that it might issue in
reliance upon this checklist should there be any willful misrepresentation
or willful lack of full disclosure on niy part.
X / /OGVl1
Siena r e Title �Cao/ g / '„ O/' ,—/77-
*tInyz-,e)
Date
CITY OF TUKWILA Ail
ENVI RMENTAL QUEST 10'd M I RE. RE ; FORM
PROJECT NAME: �euuv IS
PROJECT ADDRESS: 6-d
DATE ACCEPTED FOR FILING:
/e S/ a v�ed,v%L
fve. Sovf-4
9/7
1. DEPARTMENTAL REVIEW: (date)
❑ Building: by:
❑ Engineering: by:
l� Fire: /o - 7 y by:
❑ Planning: by:
❑.Police: by:
9f07
(revi ewer)
2. ANY PERTINENT COMMENTS:
CITY OF TUK4^1I LA )
ENVIAMEi1TAL QUESTIONNAIRE REV Vi FORM
PROJECT NAME: �e,Lwy / es f 4' ✓A40Nt
PROJECT ADDRESS: �7 dve. Sootl
DATE ACCEPTED FOR FILING: 5/7 ??
1. DEPARTMENTAL REVIEW: (date)
D Building: by:
D Engineering: by:
D Fire: by:
D% anning: by:
Police: \ u C-60\Me s'n by:
2. ANY PERTINENT COMMENTS:
(reviewer)
O.C.D.
CITY OF TUKWILA
MAY i 4 1979
CITY OF TUK4'WILA
ENVIRONMENTAL CHECKLIST FORM
This questionnaire must be completed and submitted with the application for
permit. This questionnaire must be completed by all persons applying for a
permit from the City of Tukwila, unless it is determined by the Responsible
Official that the permit is exempt or unless the applicant and Responsible
Official previously agree an Environmental Impact Statement needs to be completed.
A fee of $50.00 must accompany the filling of the Environmental Questionnaire
to cover costs of the threshold determination.
I. BACKGROUND // `/
1. Name of Proponent: �en/I 5 �/re. (by Zarr> T /
2. Address and Phone Number of Proponent: /prone) 41/5-.4g;.%5.--.334%Z
2 '/g 73/l)cJ, Mzy' rJ ,14&1
3. Date Checklist Submitted: /44y - g - /17 N t4
4. Agency Requiring Checklist: C; i o 4 ‘kc'c/
5. Name of Proposal, if applicable :niiyS
6. Nature and Brief Description of the Proposal (including but not limited
to its size, general design elements, and other factors that will give
an accurate understanding of its scope and nature):
,4 Stir /e ✓7 P ?fie in S �e g7a u rA i? / C'ori »:n 5614.-4-.7
y y �
eardge,.i7 r // P ro ?5•
(describe the physical setting of the proposal, as
7. Location of Proposal (c p y 9
well as the extent of the land area affected by any environmental im-
pacts, including any other inforriation needed to dive an accurate under-
standing of the environmental setting of the proposal):.
Jau-/-/?er/ S. e oT ' €?/.4 Ave, So . ,4,7re)e. _;c1
roll Z epcc r ' /e. o:4q,;1�
•5 717 q 'Ma I7i/ I , 3e r ✓�CC S/1 o /1
•8. Estimated Date for Completion of the Proposal: febr'aarry /4P3?,
9. List of all Permits, Licenses or Government Approvals Required for the
Proposal (federal, state and local):
Rezone, conditional use, shoreline permit, etc.
King County Hydraulics Permit
Building permit
YES NO
Y E S)< NO_
YES. NO____
• •
(d) Puget Sound Air Pollution Control Permit YES NO
(e) Sewer hook up permit YES ' NO
(f) Sign permit YES X NO
(g) Water hook up permit YES )4 NO
(h) Storm water system permit YES X NO _^
(i) Curb cut permit YES)( NO
(j) Electrical permit (State of Washington) YES X NO
(k) Plumbing permit (King County) / 1 YES )C NO
(1) Other: kjn Coctrl / 4 7
y ea ,�e ° '�
G✓ e37 �:grtor 6v -//-t /
10. Do you have any plans for future additions, expansion, or futher activity
related to or connected with this proposal? If yes, explain:
11. Do you know of any plans by others which may affect the property covered by
your proposal? If yes, explain:
12. Attach any other application form that has been completed regarding the pro-
posal; if none has been completed, but is expected to be filed at some future
date, describe the nature of such application form:
c, 7 e r -71-47/7 '� "eG� //7 # % d,/e ,
II. ENVIRONMENTAL IMPACTS
(Explanations of all "yes" and "maybe" answers are required)
1. Earth. Will the proposal result in:
(a) Unstable earth conditions or in changes in geologic
substructures?
(b) Disruptions, displacements, compaction or overcover-
ing of the soil?
(c) Change in topography or ground surface relief fea-
tures?
(d) The destruction, covering or modification of any
unique geologic or physical features?
YES MAYBE NO
(e) Any increase in wind or water erosion of soils,
either on or off the site?
(f)
Changes in deposition or erosion of beach sands, or
changes in siltation, deposition or erosion which
may modify the channel of a river or stream or the
bed of the ocean or any bay, inlet or lake?
Explanation:
2. Air. Will the proposal result in:
(a) Air emissions or deterioration of ambient air
quality?
(b) The creation of objectionable odors?
(c) Alteration of air movement, moisture
or temperature, or any change in climate, either
locally or regionally? ,,..//
Explanation: /V/ -�r.7� e 5,or/ 5' j /) tae
, )/ red 7 %rougi/ f/ Srs7en'I.
4pproded
-Health , �✓� }�'/7 C'o .
3. Water. Will the'proposal result in:
(a) Changes in currents, o,r the course or direction
of water movements, in either marine or fresh
waters?
(b) Changes in absorption rates, drainage patterns,
or the rate and amount of surface water runoff?
(c) Alterations to the course or flow of flood waters?
(d) Change in the amount of surface water in any water
body?
(e) Discharge into surface waters, or in any alteration
of surface water quality, including but not limited
to temperature, dissolved oxygen or turbidity?
(f) Alteration of the direction or rate of flow of
ground waters?
(g) Change in the quantity of ground waters, either
through direct additions or withdrawals, or through
interception of an aquifer by cuts or excavations?
-3-
YES MAYBE NO
x
• •
(h) Deterioration in ground water quality, either
through direct injection, or through the seepage
of leachate, phosphates, detergents, waterborne
virus or bacteria, or other substances into the
ground waters?
(i) Reduction in the amount of water otherwise avail-
able for public water supplies?
Explanation: �o ✓i SioJ g '�'
14dr7- ri��
w�r C sp y /4 Gloat/
�
444LdJ1C; 12ef'71"
4. Flora. Will the proposal result in:-
(a) Change in the diversity of species, or numbers
of any species of flora (including trees, shrubs,
grass, crops, microflora and aquatic plants)?
(b) Reduction of the numbers of any unique, rare or
endangered species of flora?
(c) Introduction of new species of flora into an area,
or in a barrier to the normal replenishment of
existing species?
YES MAYBE NO
(d) Reduction in acreage of any agricultural crop? _
Explanation: 1a/74c4-pJn ,i/'oa4J- 7 e �J"aih
�� ro ✓C 'Tfi•'�j 5/4c i45 ..L
0/,.//
.)1;cca/7 /,
5. Fauna. Will the proposal result in:
(a) Changes in the diversity of species, or numbers
of any species of fauna (birds, land animals
including reptiles, fish and shellfish, benthic
organisms, insects or microfauna)?
(b) Reduction of the numbers of any unique, rare or .
endangered species of fauna?
(c) Introduction of new species of fauna-into an
area, or result in a barrier to the migration
or movement of fauna?
(d) Deterioration to existing fish or wildlife
habitat?
Explanation:
6. Noise. Will the proposal increase existing noise
levels?
Explanation:
7. Light and Glare. Will the proposal produce new
light or glare?
Explanation: r%n L LG��!`' ,f5e'
,'r-e& fe4 Colic e17 7Led
lei'!/!/ 5 PiToPe r rc�•
8. Land Use. Will the proposal result in the altera-
tion of the present or planned land use
of an area?
Explanation: ",• /e = , �a ,pe�f ' %' -//
•I
E�7 /AcILi^u /�l �5
r�ie // ed
9. Natural Resources. Will the proposal result in:
(a) Increase in the rate of use of any natural
resources?
(b) Depletion of any nonrenewable natural
resource?
Explanation:
YES f1 YEE NO
10. Risk of Upset. Does the proposal involve a risk of an
explosion or the release of hazardous
substances (including, but not limited
to, oil, pesticides, chemicals or radi-
ation) in the event of an accident or
upset conditions?
Explanation:
11. Population.
Explanation:
• •
Will the proposal alter the location,
distribution, density, or growth rate
of the human population of an are?
12. Housing. Will the proposal affect existing housing,
or create a demand for additional housing?
Explanation:
13. Transportation /Circulation. Will the proposal result i
(a)
(b)
(c)
(d)
(e)
(f)
Generation of additional vehicular movement?
Effects on existing parking facilities, or
demand for new parking?
Impact upon existing transportation systems?
Alterations to present patterns of circulation
or movement of people and /or goods?
Alterations to waterborne, rail or air traffic?
Increase in traffic hazards to motor vehicles,
bicyclists or pedestrians?
Explanation: Q/7_ 5;7 25L-A, J'i/. / %'e
04e)e a 01.4/L. �Coelgfe
YES M `E NO
/.
771/•o /75 144/Je 5
14. Public Services. Will the proposal have an effect upon,
or result in a need for new or altered
governmental services in any of the
following areas:
(e)
Fire protection?
Police protection?
Schools?
Parks or other recreational facilities? •
Maintenance of public facilities, including
roads?
•
YES MAYBE NO
(f) Other governmental services?
Explanation: I% )40/ e • -7yp'`a/
s Z L{ "71j1',�"'" 4:2/2e/10,71;10/7' 714wie�/er 77Xe `13/d •
j44// '0,/ /0— r1 7-?-et/e47/04
G9�c Pi 7e,,t
15. Energy. Will the proposal result in:
(a) Use of substantial amounts of fuel or energy?
(b) Demand upon existing sources of energy, or
require the development of new sources of
energy?
Explanation:
16. Utilities. Will the proposal result in a need for
new systems, or alterations to the
following utilities:
(a) Power or natural gas?
(b) Communications systems?
(c) Water?
(d) Sewer
(e) Storm water drainage?,
(f) Solid waste and disposal?
Explanation: Al/ /. e , 44,e /1/..zirh4
17. Human Health. Will the proposal result in the crea-
tion of any health hazard or potential
health hazard (excluding mental health)?
Explanation:
• •
18. Aesthetics. Will the proposal result in the obstruc-
tion of any scenic vista or view open to
the public, or will the proposal result
in the creation of an aesthetically of-
fensive site open to public view?
Explanation:
19. Recreation. Will the proposal result in an impact
upon the quality or quantity of exist-
ing recreational opportunities?
Explanation:
20. Archeological /Histroical. Will the proposal result in
an alteration of a signifi-
cant archeological or his -
torical site, structure,
object or building?
Explanation:
CERTIFICATION BY APPLICANT:
YES MAYBE NO
I, the undersigned, state that to the best of my knowledge the above
information is true and complete. It is understood that the lead agency
may withdraw any declaration of non - significance that it might issue in
reliance upon this checklist should there be any willful misrepresentation
or willful lack of full disclosure on my part.
. G���'��r •- /AIM /— —/?7�-
Si • na re a'� Ti tl e (5 . //e) Date