Rd 1940-20

USDA
Form RD 1940-20
(Rev. 4-06)

FORM APPROVED
OMB No. 0575-0094

Position 3
Name of Project

REQUEST FOR ENVIRONMENTAL INFORMATION
Location

Item 1a.

Item

1b.
2.

Item

3.

Has a Federal, State, or Local Environmental Impact Statement or Analysis been prepared for this project?
Yes
No
Copy attached as EXHIBIT I-A.
If ''No.'' provide the information requested in Instructions as EXHIBIT I.
The State Historic Preservation Officer (SHPO) has been provided a detailed project description and has been requested to submit
comments to the appropriate Rural Development Office.
Yes
No
Date description submitted to SHPO
Are any of the following land uses or environmental resources either to be affected by the proposal or located within or adjacent to
the project site(s)? (Check appropriate box for every item of the following checklist).
Yes

No Unknown

Yes

1. Industrial.......................................

19. Dunes............................................

2. Commercial....................................

20. Estuary..........................................

3. Residential....................................

21. Wetlands.........................................

4. Agricultural.....................................

22. Floodplain.......................................

5. Grazing........................................

23. Wilderness.......................................
(designated or proposed under
the Wilderness Act)

6. Mining, Quarrying...........................
7. Forests..........................................

No Unknown

24. Wild or Scenic River.........................
(proposed or designated under the Wild
and Scenic Rivers Act)

8. Recreational.....................................

10. Parks..............................................

25. Historical, Archeological Sites...........
(Listed on the National Register of
Historic Places or which may be
eligible for listing)

11. Hospital...........................................

26. Critical Habitats................................

9. Transportation..................................

(endangered/threatened species)

12. Schools..........................................
13. Open spaces....................................

27. Wildlife...........................................
28. Air Quality.....................................

14. Aquifer Recharge Area.....................

29. Solid Waste Management..................

15. Steep Slopes....................................

30. Energy Supplies...............................

16. Wildlife Refuge................................

31. Natural Landmark............................

17. Shoreline.......................................
18. Beaches..........................................

(Listed on National Registry of Natural
Landmarks)

32. Coastal Barrier Resources System.....

Item 4. Are any facilities under your ownership, lease, or supervision to be utilized in the accomplishment of this project, either listed or under
consideration for listing on the Environmental Protection Agency's List of Violating Facilities?
Yes
No
Signed:
(Date)

(Applicant)

(Title)
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collections is 0575-0094. The time required to complete this
information collection is estimated to average 6 to 10 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.