CEQA Compliance Certification Form Name: Applicant/Grantee: Project Address: Project When was analysis completed for this Date: ceqa Project? What documents were filed for this analysis: (check all that apply) Project’s ceqa Initial Study Notice of Exemption Negative Declaration Mitigated Negative Declaration Environmental Impact Report Other Please attach all checked documents. If these forms were not completed please attach a letter from the Lead Agency explaining why, certifying the has complied with and noting the date Project ceqa that the was approved by the Lead Agency. Project Lead Agency Contact Information: Agency Name: Contact Person: Mailing Address: Phone: ( ) Email: Certification: I hereby certify that the Lead Agency listed above has determined that it has complied with the California Environmental Quality Act (ceqa) for the Project identified above and that the Project is described in adequate and sufficient detail to allow the Project’s construction or Acquisition. I certify that the ceqa analysis for this Project encompasses all aspects of the work to be completed with Grant funds. Authorized Representative Date Authorized Representative (Signature) (Printed Name and Title)
CEQA Compliance Certification Form Applicant/Grantee: Project Name: Project Address: When was ceqa analysis completed for this Project? Date: What documents were filed for this Project’s ceqa analysis: (check all that apply) Initial Study Notice of Exemption Negative Declaration Mitigated Negative Declaration Environmental Impact Report Other Please attach all checked documents. If these forms were not completed please attach a letter from the Lead Agency explaining why, certifying the Project has complied with ceqa and noting the date that the Project was approved by the Lead Agency. Lead Agency Contact Information: Agency Name: Contact Person: Mailing Address: Phone: ( ) Email: Certification: I hereby certify that the Lead Agency listed above has determined that it has complied with the California Environmental Quality Act (ceqa) for the Project identified above and that the Project is described in adequate and sufficient detail to allow the Project’s construction or Acquisition. I certify that the ceqa analysis for this Project encompasses all aspects of the work to be completed with Grant funds. Authorized Representative Date Authorized Representative (Signature) (Printed Name and Title)
final%20lwcf%20app%20guide%20state%20agencies%2012.10.13_2.docx