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E-4 NVMONMENTAL ASSESSMENT WORKSHEET <br />Note to preparers: An electronic versimn of this form is available at www. M_ -4aW-mmx& EAW Guideffnes wffl be avaHable In <br />spring I9". The Environmental Assessment worksheet provides information about a project that may have the potential for <br />significant environmental effects. The EAw is prepared by the Responsible Governmental Unit or its agents to determine whether an <br />Environmental Impact Statement should be prepared. The project proposer must supply any reasonably accessible data for but <br />should not complete the final worksheet. If a complete answer does not fit in the space allotted., a addition sheets as <br />necessary. The complete question as well as the answer must be included if the EAw is prepared electronically. <br />Mote to reviewers: Comments must be submitted to the RGU during the 30-day comment period following rice of the EAw in <br />the E 8 Monitor. Comments should address the accuracy and completeness of information, potential impacts that warrant further <br />investigation and the need for an EIS. <br />1. Project title <br />2. imposer 3. <br />Contact person <br />Title <br />Address <br />City, state, ZIP <br />Phone <br />Fax <br />E -mail <br />RGU <br />Contact person <br />Title <br />Address <br />City* state, ZIP <br />Phone <br />Fax <br />E -mail <br />4. Reason for EAw preparation (check one) <br />EIS scoping Mandatory EAw Citizen petition RGUdiscretion Proposer volunteered <br />If EAw or HIS is mandatary give EQB rule category subpart number and subpart name <br />S. Project location County <br />4 I Section <br />City/Township <br />Township�w _ illillilillillillilloINININIIIIIIIIIIIIIIIIillillillillillillilliillilliillillillillillillillillilliililill,l,ll((((,(,(,(,(,(,(,(,,, ,,,,,, age <br />Attach each of the following to the EA W: <br />• County map showing the general location of the project; <br />• U.S. Geological Survey 7.5 minute, 1,.24,000 scale reap indicating project boundaries (photocopy acceptable); <br />• Site plan showing all sigrnificant project and natural features. <br />b. Description <br />a. Provide a project summary of So wands or less to be published in the EQB Monitor. <br />b. Give a complete description of the proposed project and related new construction Attach additional sheen as necessary. <br />Emphasize construction, operation methods and features that will cause physical manipulation of the environment or will produce <br />wastes. Include modifications to existing equipment or industrial processes and significant demolition, removal or remodeling of <br />existing structures. Indicate the timing and duration of construction activities. <br />