Cal. Code Regs. Tit. 23, 6 app A

• Library: California Code of Regulations
• Edition: 2023
• Currency: Current through Register 2023 Notice Reg. No. 44, November 3, 2023
• Citation: Cal. Code Regs. Tit. 23, 6 app A
• Year: 2023

Environmental Checklist Form

(To Be Completed By Lead Agency)

Appendix to the State Water Board's CEQA regulations

Cal. Code. Regs., tit. 23, div. 3, ch. 27 sections3720-3781

THE PROJECT

1.	Project title:
__________________________________________________________
2.	Lead agency name and address:
__________________________________________________________
__________________________________________________________
__________________________________________________________
3.	Contact person and phone number:
__________________________________________________________
4.	Project location:
__________________________________________________________

1.

Project title:

__________________________________________________________

2.

Lead agency name and address:

__________________________________________________________

__________________________________________________________

__________________________________________________________

3.

Contact person and phone number:

__________________________________________________________

4.

Project location:

__________________________________________________________

5.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. The description may be a summary with a reference to other documents that contain the detailed project description.)

EVALUATION OF THE ENVIRONMENTAL IMPACTS IN THE CHECKLIST

1.The board must complete an environmental checklist prior to the adoption of plans or policies for the Basin/208 Planning program as certified by the Secretary for Natural Resources. The checklist becomes a part of the Substitute Environmental Documentation (SED).

2.For each environmental category in the checklist, the board must determine whether the project will cause any adverse impact. If there are potential impacts that are not included in the sample checklist, those impacts should be added to the checklist.

3.If the board determines that a particular adverse impact may occur as a result of the project, then the checklist boxes must indicate whether the impact is "Potentially Significant," "Less than Significant with Mitigation Incorporated," or "Less than Significant."

a."Potentially Significant Impact" applies if there is substantial evidence that an impact may be significant. If there are one or more "Potentially Significant Impact" entries on the checklist, the SED must include an examination of feasible alternatives and mitigation measures for each such impact, similar to the requirements for preparing an environmental impact report.

b."Less than Significant with Mitigation Incorporated" applies if the board or another agency incorporates mitigation measures into the SED that will reduce an impact that is "Potentially Significant" to a "Less than Significant Impact." If the board does not require the specific mitigation measures itself, then the board must be certain that the other agency will in fact incorporate those measures.

c."Less than Significant" applies if the impact will not be significant, and mitigation is therefore not required.

d.If there will be no impact, check the box under "No Impact."

4.The board must provide a brief explanation for each "Potentially Significant," "Less than Significant with Mitigation Incorporated," "Less than Significant," or "No Impact" determination in the checklist. The explanation may be included in the written report described in section 3777(a)(1) or in the checklist itself. The explanation of each issue should identify: (a) the significance criteria or threshold, if any, used to evaluate each question; and (b) the specific mitigation measure(s) identified, if any, to reduce the impact to less than significant. The board may determine the significance of the impact by considering factual evidence, agency standards, or thresholds. If the "No Impact" box is checked, the board should briefly provide the basis for that answer. If there are types of impacts that are not listed in the checklist, those impacts should be added to the checklist.

5.The board must include mandatory findings of significance if required by CEQA Guidelines section 15065.

6.The board should provide references used to identify potential impacts, including a list of information sources and individuals contacted.

ISSUES

Less Than
Potentially	Significant	Less Than
Significant	with 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 FOREST 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 Boards.
Would the project:
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	[ ]	[ ]	[ ]

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