75D - PH - VMT AND CEQA GUIDELINES

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INFILL ENVIRONMENTAL CHECKLIST FORM NOTE: This sample form is intended to assist lead agencies in assessing infill projects according to the procedures provided in Section 21094.5 of the Public Resources Code. Lead agencies may customize this form as appropriate, provided that the contents satisfies the requirements in Section 15183.3 of the State CEQA Guidelines. 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. Prior Environmental Document(s) Analyzing the Effects of the Infill Project: 9. Location of Prior Environmental Document(s) Analyzing the Effects of the Infill Project (including State Clearinghouse Number, if assigned): 10. 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 sheet(s) if necessary.) 11. Surrounding Land Uses and Setting: (Briefly describe the project's surroundings, including any prior uses of the project site, or, if vacant, describe the urban uses that exist on at least 75% of the project's perimeter.) 12. Other public agencies whose approval is required (e.g., permits, financing approval, or participation agreement): 13. 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, is there a plan for consultation that includes, for example, the determination of significance of impacts to tribal cultural resources, procedures regarding confidentiality, etc.? Note: Conducting consultation early in the CEQA process allows tribal governments, lead agencies, and project Infill Environmental Ch cldist Fmm Pagel of 20 FORM "S" 75D-227