Az Vacant Land Disclosure

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					                E-3 DETERMINATION FORM

                                        ADOH Contract No:

                                     ADOH ENVIRONMENTAL REVIEW RECORD

                                              DETERMINATION FORM

Determine the type of environmental review necessary by checking the box that best describes the activity. All
activities must complete a Level of Review Determination (Form E-3.1) in addition to this Form, except
Owner-Occupied Rehabilitation using the RER.

     1.   The following are EXEMPT activities or components of an activity (§58.34). Check the appropriate box and
          complete the required documentation for Exempt activities.
          Environmental or other studies, resource identification, development of plans and strategies
          Information or financial services
          Public services that will not have a physical impact or result in any physical changes. Examples:
          Programs for employment, crime prevention, child care, health, drug abuse, education, counseling, energy
          conservation, welfare or recreational needs
          Inspections and testing of properties for hazards or defects
          Purchase of insurance
          Purchase of tools
          Professional services such as engineering, design, architectural, planning, appraisal, rehab services, etc.
          Technical assistance and training
          Interim assistance

     2.   The following activities are Categorically Excluded (not subject to §58.5) and therefore considered
          EXEMPT. Check the appropriate box and complete the required documentation for Exempt activities.
          Supportive services such as housing services, permanent housing placement, nutritional services, short
          term payments for rent/mortgage/utility costs, and assistance in gaining access to government benefits
          and services.
          Operating costs including maintenance, security, operation, utilities, furnishings, equipment, supplies, staff
          training and recruitment and other incidental costs.
          Equipment necessary to the operation of a service such as a fire truck, ambulance, transportation service
          vehicles, etc.
     2.    EXEMPT Activities (cont’d)
           Economic development activities such as equipment purchase, operating expenses and similar costs not
           associated with construction or expansion of existing operations.
           Activities to assist homeownership of existing or new dwelling units not assisted with federal funds
           including closing costs and down payment assistance, interest buy downs and similar activities that result
           in the transfer of title to a property. If the home to be acquired is located in a floodplain Flood
           Insurance under the National Flood Insurance Program must be obtained and maintained for the
           economic life of the project, in the amount of the total project and a copy of the flood insurance
           policy declaration must be kept in the ERR. If the home to be acquired is located in an airport clear
           zone a Disclosure Statement must be provided to the buyer and a copy of the signed disclosure
           statement must be maintained in the ERR.

B.   CATEGORICALLY EXCLUDED activities. Check the appropriate box and complete the required
     documentation for CE activities.
            An activity from Section A.2 that is in or will impact on a floodplain or airport clear zone.
            Acquisition, repair, improvement, reconstruction or rehabilitation of public facilities and improvements
            (does not include buildings) when the facilities/improvements are in
            place and will be retained in the same use without change in size or capacity of more than 20%.
            Examples: Replacement of water or sewer lines, sidewalk/curb reconstruction, street repaving.
            Architectural barrier removal
            Rehabilitation of residential buildings, only IF:
                no change in the land use, the density is not increased beyond 4 units and the footprint of the
                building is not increased in a floodplain
            Non residential rehabilitation (commercial, industrial, public buildings) only IF:
                No change in land use (from commercial to industrial, etc.); and
                Facility/improvement in place and change in size or capacity will not exceed 20%.
            Acquisition or disposition of an existing 1-4 family dwelling (includes reconstruction)
            Acquisition or disposition of an existing structure or acquisition of vacant land provided that the structure
            or land acquired or disposed of will be retained for the same use.

C.   Those activities not described in Section A or B require an ENVIRONMENTAL ASSESSMENT. Check the box
     below and complete the required documentation for EA activities.

           This project is Exempt

           This project is Categorically Excluded

           This project requires an Environmental Assessment

Certifying Officer (insert name and title)

 ___________________________________                      __________________________________________
Signature                                                 Date

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