Environmental Assessment Form (EAF) This form is to assist the reviewers in determining whether a proposed action could cause significant natural and socioeconomic environmental effects and thus require an environmental effects report. Department _______________________________ Division _________________________ Other ____________________________________________________________________ Project Title _______________________________________________________________ Predicted Dates: Commencement _______________________________________________ Completion _____________________________ Projected Cost _______________________

1. A. Background Information.

   1. (1) Give a brief description of the proposed action/project(s).
   2. (2) Describe the geographical area(s) which will be affected by the action/project(s); specifically locate the project by using the Maryland coordinate grid system; include distinguishing natural and man-made features and a brief description of the present use of the area(s). Include a suitable location map (sketch map or copy of U.S. Geological Survey Map, etc.).

2. B. Assessment of Significant Environmental Effects.

   1. (1) The following questions should be answered by placing a check in the appropriate column(s). If desirable, the “comments attached” column can be checked by itself or in combination with an answer of “yes” or “no” to provide additional information or to overcome an affirmative presumption.
   2. (2) In answering the questions, the significant beneficial and adverse, short-term and long-term effects of the proposed action, on site and off site during construction and operation should be considered.

   3. (3) All questions should be answered as if the agency is subject to the same requirements as a private person requesting a license or permit from the State or federal government.

      	Yes	No	Comments Attached
      A. Land Use Considerations.
      1. Will the action be within the 100-year flood plain?	___	___	______
      2. Will the action require a permit for construction or alteration within the 50 year flood plain?	___	___	______
      3. Will the action require a permit for dredging, filling, draining, or alteration of a wetland?	___	___	______
      4. Will the action require a permit for the construction or operation of facilities for solid waste disposal including dredge and excavation spoil?	___	___	______
      5. Will the action occur on slopes exceeding 15 percent?	___	___	______
      6. Will the action require a grading plan or a sediment control permit?	___	___	______
      7. Will the action require a mining permit for deep or surface mining?	___	___	______
      8. Will the action require a permit for drilling a gas or oil well?	___	___	______
      9. Will the action require a permit for airport construction?	___	___	______
      10. Will the action require a permit for the crossing of the Potomac River by conduits, cables, or other like devices?	___	___	______
      11. Will the action affect the use of a public recreation area, park, forest, wildlife management area, scenic river, or wildland?	___	___	______
      12. Will the action affect the use of any natural or man-made features that are unique to the county, State, or nation?	___	___	______
      13. Will the action affect the use of an archaeological or historical site or structure?	___	___	______
      B. Water Use Considerations.
      14. Will the action require a permit for the change of the course, current, or cross section of a stream or other body of water?	___	___	______
      15. Will the action require the construction alteration, or removal of a dam, reservoir, or waterway obstruction?	___	___	______
      16. Will the action change the overland flow of storm water or reduce the absorption capacity of the ground?	___	___	______
      17. Will the action require a permit for the drilling of a water well?	___	___	______
      18. Will the action require a permit for water appropriation?	___	___	______
      19. Will the action require a permit for the construction and operation of facilities treatment or distribution of water?	___	___	______
      20. Will the project require a permit for the construction and operation of facilities for sewage treatment or land disposal of liquid waste derivatives?	___	___	______
      21. Will the action result in any discharge into surface or subsurface water?	___	___	______
      22. If so, will the discharge affect ambient water quality limits or require a discharge permit?	___	___	______
      C. Air Use Considerations.
      23. Will the action result in any discharge into the air?	___	___	______
      24. If so, will the discharge affect ambient air quality limits or produce a disagreeable odor?	___	___	______
      25. Will the action generate additional noise which differs in character or level from present conditions?	___	___	______
      26. Will the action preclude future use of related air space?	___	___	______
      27. Will the action generate any radiological, electrical, magnetic, or light influences?	___	___	______
      D. Plants and Animals.
      28. Will the action cause the disturbance, reduction, or loss of any rare, unique, or valuable plant or animal?	___	___	______
      29. Will the action result in the significant reduction or loss of any fish or wildlife habitats?	___	___	______
      30. Will the action require a permit for the use of pesticides, herbicides, or other biological, chemical, or radiological control agents?	___	___	______
      E. Socio-Economic.
      31. Will the action result in a preemption of division of properties or impair their economic use?	___	___	______
      32. Will the action cause relocation of activities or structures, or result in a change in the population density or distribution?	___	___	______
      33. Will the action alter land values?	___	___	______
      34. Will the action affect traffic flow and volume?	___	___	______
      35. Will the action affect the production, extraction, harvest, or potential use of a scarce or economically important resource?	___	___	______
      36. Will the action require a license to construct a sawmill or other plant for manufacture of forest products?	___	___	______
      37. Is the action in accord with federal, state, regional, and local comprehensive or functional plans—including zoning?	___	___	______
      38. Will the action affect the employment opportunities for persons in the area?	___	___	______
      39. Will the action affect the ability of the area to attract new sources of tax revenue?	___	___	______
      40. Will the action discourage present sources of tax revenue from remaining in the area, or affirmatively encourage them to relocate elsewhere?	___	___	______
      41. Will the action affect the ability of the area to attract tourism?	___	___	______
      F. Other Considerations.
      42. Could the action endanger the public health, safety, or welfare?	___	___	______
      43. Could the action be eliminated without deleterious effects to the public health, safety, welfare, or the natural environment?	___	___	______
      44. Will the action be of Statewide significance?	___	___	______
      45. Are there any other plans or actions (federal, State, county, or private) that, in conjunction with the subject action, could result in a cumulative or synergistic impact on the public health, safety, welfare, or environment?	___	___	______
      46. Will the action require additional power generation or transmission capacity?	___	___	______
      G. Conclusion.
      47. This Agency will develop a complete Environmental Effects Report on the proposed action.	___	___	______

3. C. Summary of Environmental Effects Report. Attached to the front of every environmental effects report should be a one or two page summary in substantially the following form: Letterhead of issuing agency (or: “This statement has been issued by (name of agency).”)

   1. 1. Kind of action: _________________________ request for legislative appropriation, i.e., requests for capital budget items, requests for encumbrances upon special funds or trusts, and bond issues. ___________ Other legislative action, i.e., requests for proposed legislative acts and/or expansion of existing acts or agency authority, or passage of laws which will require legislative appropriation.
   2. 2. Official responsible for issuance of this statement (name, address, telephone).
   3. 3. Official responsible as a contact for questions in regard to the environmental effects report.
   4. 4. Name, location, and brief description of the action.

   5. 5. Summary of environmental effects for the following:

      Comments	None	Adverse	Beneficial
      A. Land ______________________________________
      ____________________________________________	_____	______	_______
      B. Water _____________________________________
      ____________________________________________	_____	______	_______
      C. Air ________________________________________
      ____________________________________________	_____	______	_______
      D. Plants _____________________________________
      ____________________________________________	_____	______	_______
      E. Animals ___________________________________
      ____________________________________________	_____	______	_______
      F. Socio-economic _____________________________
      ____________________________________________	_____	______	_______
      G. Other _____________________________________
      ____________________________________________	_____	______	_______

   6. 6. List of alternatives considered.
   7. 7. List all federal, State, and local agencies and other sources from which written comments have been requested.
   8. 8. Date statement was sent to Clearinghouse.

Authority: Natural Resources Article, §§1-301—1-305, Annotated Code of Maryland

Effective date: October 29, 1975 (2:24 Md. R. 1482)

Regulation .03B amended effective November 12, 1990 (17:22 Md. R. 2657)

Regulation .04 amended effective November 12, 1990 (17:22 Md. R. 2657)

Regulation .05A amended effective November 12, 1990 (17:22 Md. R. 2657)

Regulation .06C amended effective November 12, 1990 (17:22 Md. R. 2657)

Regulation .07 amended effective August 28, 1995 (22:17 Md. R. 1319)