APPENDIX G: ENVIRONMENTAL CHECKLIST FORM

NOTE: The following is a sample form that may be tailored to satisfy individual agencies’ needs and project circumstances. It may be used to meet the requirements for an initial study when the criteria set forth in CEQA Guidelines have been met. Substantial evidence of potential impacts that are not listed on this form must also be considered. The sample questions in this form are intended to encourage thoughtful assessment of impacts, and do not necessarily represent thresholds of significance.

1. Project title: Click here to enter text.

2. Lead agency name and address: Click here to enter text.

3. Contact person and phone number: Click here to enter text.

4. Project location: Click here to enter text.

5. Project sponsor's name and address: Click here to enter text.

6. General plan designation: Click here to enter text.

7. Zoning: Click here to enter text.

8. 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.)

Click here to enter text.

9. Surrounding land uses and setting: Briefly describe the project's surroundings:

Click here to enter text.

10. Other public agencies whose approval is required (e.g., permits, financing approval, or participation agreement.):

Click here to enter text.

11. 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.?

Click here to enter text.

NOTE: Conducting consultation early in the CEQA process allows tribal governments, lead agencies, and project proponents to discuss the level of environmental review, identify and address potential adverse impacts to tribal cultural resources, and reduce the potential for delay and conflict in the environmental review process. (See Public Resources Code section 21080.3.2.) Information may also be available from the California Native American Heritage Commission’s Sacred Lands File per Public Resources Code section 5097.96 and the California Historical Resources Information System administered by the California Office of Historic Preservation. Please also note that Public Resources Code section 21082.3(c) contains provisions specific to confidentiality.

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Association of Environmental Professionals 2025

CEQA Guidelines Appendices