Ceqa Appendix G Form – Fill Out and Use This PDF

Association of Environmental Professionals 2017

CEQA Guidelines Appendices

APPENDIX G:

ENVIRONMENTAL CHECKLIST FORM

NOTE: The following is a sample form and may be tailored to satisfy individual agencies’ needs and project circumstances. It may be used to meet the requirements for an initial study when the criteria set forth in CEQA Guidelines have been met. Substantial evidence of potential impacts that are not listed on this form must also be considered. The sample questions in this form are intended to encourage thoughtful assessment of impacts, and do not necessarily represent thresholds of significance.

1.Project title:

2.Lead agency name and address:

3.Contact person and phone number:

4.Project location:

5.Project sponsor’s name and address:

6. General plan designation: _______________________ 7. Zoning:

8.Description of project: (Describe the whole action involved, including but not limited to later phases of the project, and any secondary, support, or off-site features necessary for its implementation. Attach additional sheets if necessary.)

9.Surrounding land uses and setting: Briefly describe the project’s surroundings:

10.Other public agencies whose approval is required (e.g., permits, financing approval, or participation agreement.)

11.Have California Native American tribes traditionally and culturally affiliated with the project area requested consultation pursuant to Public Resources Code section 21080.3.1? If so, has consultation begun?___________________________________________________________

Note: Conducting consultation early in the CEQA process allows tribal governments, lead agencies, and project proponents to discuss the level of environmental review, identify and address potential adverse impacts to tribal cultural resources, and reduce the potential for delay and conflict in the environmental review process. (See Public Resources Code section

21083.3.2.) Information may also be available from the California Native American Heritage Commission’s Sacred Lands File per Public Resources Code section 5097.96 and the California Historical Resources Information System administered by the California Office of Historic Preservation. Please also note that Public Resources Code section 21082.3(c) contains provisions specific to confidentiality.

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ENVIRONMENTAL FACTORS POTENTIALLY AFFECTED:

The environmental factors checked below would be potentially affected by this project, involving at least one impact that is a “Potentially Significant Impact” as indicated by the checklist on the following pages.

DETERMINATION: (To be completed by the Lead Agency)

On the basis of this initial evaluation:

I find that the proposed project COULD NOT have a significant effect on the environment, and a NEGATIVE DECLARATION will be prepared.

I find that although the proposed project could have a significant effect on the environment, there will not be a significant effect in this case because revisions in the project have been made by or agreed to by the project proponent. A MITIGATED NEGATIVE DECLARATION will be prepared.

I find that the proposed project MAY have a significant effect on the environment, and an ENVIRONMENTAL IMPACT REPORT is required.

I find that the proposed project MAY have a “potentially significant impact” or “potentially significant unless mitigated” impact on the environment, but at least one effect 1) has been adequately analyzed in an earlier document pursuant to applicable legal standards, and 2) has been addressed by mitigation measures based on the earlier analysis as described on attached sheets. An ENVIRONMENTAL IMPACT REPORT is required, but it must analyze only the effects that remain to be addressed.

I find that although the proposed project could have a significant effect on the environment, because all potentially significant effects (a) have been analyzed adequately in an earlier EIR or NEGATIVE DECLARATION pursuant to applicable standards, and (b) have been avoided or mitigated pursuant to that earlier EIR or NEGATIVE DECLARATION, including revisions or mitigation measures that are imposed upon the proposed project, nothing further is required.

Signature		Date
Signature		Date

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EVALUATION OF ENVIRONMENTAL IMPACTS:

1)A brief explanation is required for all answers except “No Impact” answers that are

adequately supported by the information sources a lead agency cites in the parentheses following each question. A “No Impact” answer is adequately supported if the referenced

information sources show that the impact simply does not apply to projects like the one involved (e.g., the project falls outside a fault rupture zone). A “No Impact” answer should be explained where it is based on project-specific factors as well as general standards (e.g., the project will not expose sensitive receptors to pollutants, based on a project-specific screening analysis).

2)All answers must take account of the whole action involved, including off-site as well as on-site, cumulative as well as project-level, indirect as well as direct, and construction as well as operational impacts.

3)Once the lead agency has determined that a particular physical impact may occur, then the

checklist answers must indicate whether the impact is potentially significant, less than significant with mitigation, or less than significant. “Potentially Significant Impact” is

appropriate if there is substantial evidence that an effect may be significant. If there are one or more “Potentially Significant Impact” entries when the determination is made, an EIR is required.

4)“Negative Declaration: Less Than Significant With Mitigation Incorporated” applies where the incorporation of mitigation measures has reduced an effect from “Potentially Significant Impact” to a “Less Than Significant Impact.” The lead agency must describe the mitigation

measures, and briefly explain how they reduce the effect to a less than significant level (mitigation measures from “Earlier Analyses,” as described in (5) below, may be cross- referenced).

5)Earlier analyses may be used where, pursuant to the tiering, program EIR, or other CEQA process, an effect has been adequately analyzed in an earlier EIR or negative declaration. Section 15063(c)(3)(D). In this case, a brief discussion should identify the following:

a)Earlier Analysis Used. Identify and state where they are available for review.

b)Impacts Adequately Addressed. Identify which effects from the above checklist were within the scope of and adequately analyzed in an earlier document pursuant to applicable legal standards, and state whether such effects were addressed by mitigation measures based on the earlier analysis.

c)Mitigation Measures. For effects that are “Less than Significant with Mitigation Measures Incorporated,” describe the mitigation measures which were incorporated or refined from the earlier document and the extent to which they address site-specific conditions for the project.

6)Lead agencies are encouraged to incorporate into the checklist references to information sources for potential impacts (e.g., general plans, zoning ordinances). Reference to a previously prepared or outside document should, where appropriate, include a reference to the page or pages where the statement is substantiated.

7)Supporting Information Sources: A source list should be attached, and other sources used or individuals contacted should be cited in the discussion.

8)This is only a suggested form, and lead agencies are free to use different formats; however,

lead agencies should normally address the questions from this checklist that are relevant to a project’s environmental effects in whatever format is selected.

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9)The explanation of each issue should identify:

a)the significance criteria or threshold, if any, used to evaluate each question; and

b)the mitigation measure identified, if any, to reduce the impact to less than significance

SAMPLE QUESTION

Issues:

Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

I. AESTHETICS. Would the project:

a)Have a substantial adverse effect on a scenic vista?

b)Substantially damage scenic resources, including, but not limited to, trees, rock outcroppings, and historic buildings within a state scenic highway?

c)Substantially degrade the existing visual character or quality of the site and its surroundings?

d)Create a new source of substantial light or glare which would adversely affect day or nighttime views in the area?

II.AGRICULTURE AND FORESTRY RESOURCES. In determining whether impacts to agricultural resources are significant environmental effects, lead agencies may refer to the California Agricultural Land Evaluation and Site Assessment Model (1997) prepared by the California Dept. of Conservation as an optional model to use in assessing impacts on agriculture and farmland. In determining whether impacts to forest resources, including timberland, are significant environmental effects, lead agencies may refer to information compiled by the California Department of

Forestry and Fire Protection regarding the state’s inventory of forest land, including the Forest and Range Assessment Project and the Forest Legacy Assessment project; and forest carbon measurement methodology provided in Forest Protocols adopted by the California Air Resources Board. Would the project:

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

a)Convert Prime Farmland, Unique Farmland, or Farmland of Statewide Importance (Farmland), as shown on the maps prepared pursuant to the Farmland Mapping and Monitoring Program of the California Resources Agency, to non-agricultural use?

b)Conflict with existing zoning for agricultural use, or a Williamson Act contract?

c)Conflict with existing zoning for, or cause rezoning of, forest land (as defined in Public Resources Code section 12220(g)), timberland (as defined by Public Resources Code section 4526), or timberland zoned Timberland Production (as defined by Government Code section 51104(g))?

d)Result in the loss of forest land or conversion of forest land to non-forest use?

e)Involve other changes in the existing environment which, due to their location or nature, could result in conversion of Farmland, to non-agricultural use or conversion of forest land to non-forest use?

III.AIR QUALITY. Where available, the significance criteria established by the applicable air quality management or air pollution control district may be relied upon to make the following determinations. Would the project:

a)Conflict with or obstruct implementation of the applicable air quality plan?

b)Violate any air quality standard or contribute substantially to an existing or projected air quality violation?

c)Result in a cumulatively considerable net

increase of any criteria pollutant for which the project region is non-attainment under an applicable federal or state ambient air quality standard (including releasing emissions which exceed quantitative thresholds for ozone precursors)?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

d)Expose sensitive receptors to substantial pollutant concentrations?

e)Create objectionable odors affecting a substantial number of people?

IV. BIOLOGICAL RESOURCES:

Would the project:

a)Have a substantial adverse effect, either directly or through habitat modifications, on any species identified as a candidate, sensitive, or special status species in local or regional plans, policies, or regulations, or by the California Department of Fish and Game or U.S. Fish and Wildlife Service?

b)Have a substantial adverse effect on any riparian habitat or other sensitive natural community identified in local or regional plans, policies, regulations or by the California Department of Fish and Game or US Fish and Wildlife Service?

c)Have a substantial adverse effect on federally protected wetlands as defined by Section 404 of the Clean Water Act (including, but not limited to, marsh, vernal pool, coastal, etc.) through direct removal, filling, hydrological interruption, or other means?

d)Interfere substantially with the movement of any native resident or migratory fish or wildlife species or with established native resident or migratory wildlife corridors, or impede the use of native wildlife nursery sites?

e)Conflict with any local policies or ordinances protecting biological resources, such as a tree preservation policy or ordinance?

f)Conflict with the provisions of an adopted Habitat Conservation Plan, Natural Community Conservation Plan, or other approved local, regional, or state habitat conservation plan?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

V. CULTURAL RESOURCES. Would the project:

a)Cause a substantial adverse change in the significance of a historical resource as defined in § 15064.5?

b)Cause a substantial adverse change in the significance of an archaeological resource pursuant to § 15064.5?

c)Directly or indirectly destroy a unique paleontological resource or site or unique geologic feature?

d)Disturb any human remains, including those interred outside of formal cemeteries?

VI. GEOLOGY AND SOILS. Would the project:

a)Expose people or structures to potential substantial adverse effects, including the risk of loss, injury, or death involving:

i)Rupture of a known earthquake fault, as delineated on the most recent Alquist-Priolo Earthquake Fault Zoning Map issued by the State Geologist for the area or based on other substantial evidence of a known fault? Refer to Division of Mines and Geology Special Publication 42.

ii) Strong seismic ground shaking?

iii)Seismic-related ground failure, including liquefaction?

iv) Landslides?

b)Result in substantial soil erosion or the loss of topsoil?

c)Be located on a geologic unit or soil that is unstable, or that would become unstable as a result of the project, and potentially result in on- or off-site landslide, lateral spreading, subsidence, liquefaction or collapse?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

d)Be located on expansive soil, as defined in Table 18-1-B of the Uniform Building Code (1994), creating substantial risks to life or property?

e)Have soils incapable of adequately supporting the use of septic tanks or alternative waste water disposal systems where sewers are not available for the disposal of waste water?

VII. GREENHOUSE GAS EMISSIONS.

Would the project:

a)Generate greenhouse gas emissions, either directly or indirectly, that may have a significant impact on the environment?

b)Conflict with an applicable plan, policy or regulation adopted for the purpose of reducing the emissions of greenhouse gases?

VIII. HAZARDS AND HAZARDOUS

MATERIALS. Would the project:

a)Create a significant hazard to the public or the environment through the routine transport, use, or disposal of hazardous materials?

b)Create a significant hazard to the public or

the environment through reasonably foreseeable upset and accident conditions involving the release of hazardous materials into the environment?

c)Emit hazardous emissions or handle hazardous or acutely hazardous materials, substances, or waste within one-quarter mile of an existing or proposed school?

d)Be located on a site which is included on a list of hazardous materials sites compiled pursuant to Government Code Section 65962.5 and, as a result, would it create a significant hazard to the public or the environment?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

e)For a project located within an airport land use plan or, where such a plan has not been adopted, within two miles of a public airport or public use airport, would the project result in a safety hazard for people residing or working in the project area?

f)For a project within the vicinity of a private airstrip, would the project result in a safety hazard for people residing or working in the project area?

g)Impair implementation of or physically interfere with an adopted emergency response plan or emergency evacuation plan?

h)Expose people or structures to a significant risk of loss, injury or death involving wildland fires, including where wildlands are adjacent to urbanized areas or where residences are intermixed with wildlands?

IX. HYDROLOGY AND WATER QUALITY.

Would the project:

a)Violate any water quality standards or waste discharge requirements?

b)Substantially deplete groundwater supplies or interfere substantially with groundwater recharge such that there would be a net deficit in aquifer volume or a lowering of the local groundwater table level (e.g., the production rate of pre-existing nearby wells would drop to a level which would not support existing land uses or planned uses for which permits have been granted)?

c)Substantially alter the existing drainage pattern of the site or area, including through the alteration of the course of a stream or river, in a manner which would result in substantial erosion or siltation on- or off-site?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

d)Substantially alter the existing drainage pattern of the site or area, including through the alteration of the course of a stream or river, or substantially increase the rate or amount of surface runoff in a manner which would result in flooding on- or off-site?

e)Create or contribute runoff water which would exceed the capacity of existing or planned stormwater drainage systems or provide substantial additional sources of polluted runoff?

f)Otherwise substantially degrade water quality?

g)Place housing within a 100-year flood hazard area as mapped on a federal Flood Hazard Boundary or Flood Insurance Rate Map or other flood hazard delineation map?

h)Place within a 100-year flood hazard area structures which would impede or redirect flood flows?

i)Expose people or structures to a significant risk of loss, injury or death involving flooding, including flooding as a result of the failure of a levee or dam?

j) Inundation by seiche, tsunami, or mudflow?

X. LAND USE AND PLANNING. Would the project:

a) Physically divide an established community?

b)Conflict with any applicable land use plan, policy, or regulation of an agency with jurisdiction over the project (including, but not limited to the general plan, specific plan, local coastal program, or zoning ordinance) adopted for the purpose of avoiding or mitigating an environmental effect?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

c)Conflict with any applicable habitat conservation plan or natural community conservation plan?

XI. MINERAL RESOURCES. Would the project:

a)Result in the loss of availability of a known mineral resource that would be of value to the region and the residents of the state?

b)Result in the loss of availability of a locally- important mineral resource recovery site delineated on a local general plan, specific plan or other land use plan?

XII. NOISE -- Would the project result in:

a)Exposure of persons to or generation of noise levels in excess of standards established in the local general plan or noise ordinance, or applicable standards of other agencies?

b)Exposure of persons to or generation of excessive groundborne vibration or groundborne noise levels?

c)A substantial permanent increase in ambient noise levels in the project vicinity above levels existing without the project?

d)A substantial temporary or periodic increase in ambient noise levels in the project vicinity above levels existing without the project?

e)For a project located within an airport land use plan or, where such a plan has not been adopted, within two miles of a public airport or public use airport, would the project expose people residing or working in the project area to excessive noise levels?

f)For a project within the vicinity of a private airstrip, would the project expose people residing or working in the project area to excessive noise levels?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

XIII. POPULATION AND HOUSING. Would the project:

a)Induce substantial population growth in an area, either directly (for example, by proposing new homes and businesses) or indirectly (for example, through extension of roads or other infrastructure)?

b)Displace substantial numbers of existing housing, necessitating the construction of replacement housing elsewhere?

c)Displace substantial numbers of people,

necessitating the construction of replacement housing elsewhere?

XIV. PUBLIC SERVICES.

a)Would the project result in substantial adverse physical impacts associated with the provision of new or physically altered governmental facilities, need for new or physically altered governmental facilities, the construction of which could cause significant environmental impacts, in order to maintain acceptable service ratios, response times or other performance objectives for any of the public services:

Fire protection?

Police protection?

Schools?

Parks?

Other public facilities?

XV. RECREATION.

a)Would the project increase the use of existing neighborhood and regional parks or other recreational facilities such that substantial physical deterioration of the facility would occur or be accelerated?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

b)Does the project include recreational facilities or require the construction or expansion of recreational facilities which might have an adverse physical effect on the environment?

XVI. TRANSPORTATION/TRAFFIC. Would the project:

a)Conflict with an applicable plan, ordinance or policy establishing measures of effectiveness for the performance of the circulation system, taking into account all modes of transportation including mass transit and non-motorized travel and relevant components of the circulation system, including but not limited to intersections, streets, highways and freeways, pedestrian and bicycle paths, and mass transit?

b)Conflict with an applicable congestion management program, including, but not limited to level of service standards and travel demand measures, or other standards established by the county congestion management agency for designated roads or highways?

c)Result in a change in air traffic patterns, including either an increase in traffic levels or a change in location that results in substantial safety risks?

d)Substantially increase hazards due to a design feature (e.g., sharp curves or dangerous intersections) or incompatible uses (e.g., farm equipment)?

e) Result in inadequate emergency access?

f)Conflict with adopted policies, plans, or programs regarding public transit, bicycle, or pedestrian facilities, or otherwise decrease the performance or safety of such facilities?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

XVII. Tribal Cultural Resources.

Would the project cause a substantial adverse change in the significance of a tribal cultural resource, defined in Public Resources Code section 21074 as either a site, feature, place, cultural landscape that is geographically defined in terms of the size and scope of the landscape, sacred place, or object with cultural value to a California Native American tribe, and that is:

a)Listed or eligible for listing in the California Register of Historical Resources, or in a local register of historical resources as defined in Public Resources Code section 5020.1(k), or

b)A resource determined by the lead agency, in its discretion and supported by substantial evidence, to be significant pursuant to criteria set forth in subdivision (c) of Public Resources Code Section 5024.1. In applying the criteria set forth in subdivision (c) of Public Resources Code Section 5024.1, the lead agency shall consider the significance of the resource to a California Native American tribe.

XVIIXVIII. UTILITIES AND SERVICE

SYSTEMS.

Would the project:

a)Exceed wastewater treatment requirements of the applicable Regional Water Quality Control Board?

b)Require or result in the construction of new water or wastewater treatment facilities or expansion of existing facilities, the construction of which could cause significant environmental effects?

c)Require or result in the construction of new storm water drainage facilities or expansion of existing facilities, the construction of which could cause significant environmental effects?

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Less Than

Significant

Potentially with Less Than

Significant Mitigation Significant No

Impact Incorporated Impact Impact

d)Have sufficient water supplies available to serve the project from existing entitlements and resources, or are new or expanded entitlements needed?

e)Result in a determination by the wastewater treatment provider which serves or may serve

the project that it has adequate capacity to serve the project’s projected demand in addition to the provider’s existing commitments?

f)Be served by a landfill with sufficient

permitted capacity to accommodate the project’s solid waste disposal needs?

g)Comply with federal, state, and local statutes and regulations related to solid waste?

XVIIIXVIV. MANDATORY FINDINGS OF

SIGNIFICANCE.

a)Does the project have the potential to degrade the quality of the environment, substantially reduce the habitat of a fish or wildlife species, cause a fish or wildlife population to drop below self-sustaining levels, threaten to eliminate a plant or animal community, reduce the number o restrict the range of a rare or endangered plant or animal or eliminate important examples of the major periods of California history or prehistory?

b)Does the project have impacts that are

individually limited, but cumulatively considerable? (“Cumulatively considerable” means that the incremental effects of a project are considerable when viewed in connection with the effects of past projects, the effects of other current projects, and the effects of probable future projects)?

c)Does the project have environmental effects which will cause substantial adverse effects on human beings, either directly or indirectly?

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Note: Authority cited: Sections 21083 and 21083.05, Public Resources Code. Reference: Section 65088.4, Gov. Code; Sections 21080(c), 21080.1, 21080.3, 21083, 21083.05, 21083.3, 21093, 21094, 21095, and 21151, Public Resources Code; Sundstromv. Countyof Mendocino,(1988) 202 Cal.App.3d 296; Leonoff v. MontereyBoardofSupervisors, (1990) 222 Cal.App.3d 1337; Eureka CitizensforResponsible Govt.v.CityofEureka (2007) 147 Cal.App.4th 357; ProtecttheHistoricAmadorWaterways v. AmadorWater Agency (2004) 116 Cal.App.4th at 1109; SanFranciscans UpholdingtheDowntown Planv. CityandCountyof SanFrancisco (2002) 102 Cal.App.4th 656.

Revised 2016

Authority:PublicResources Code sections21083and21083.09

Reference:PublicResourcesCode sections21073,21074,21080.3.1,21080.3.2,21082.3/21084.2and21084.3

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