Certification of Consistency

Step 1 - Agency Profile

A. GOVERNMENT AGENCY:

Government Agency:

Primary Contact:

Address:

City, State, Zip:

Telephone/Fax:

E-mail Address:

B. GOVERNMENT AGENCY ROLE IN COVERED ACTION:

Step 2 - Covered Action Profile

A. COVERED ACTION PROFILE:

B. PROPONENT CARRYING OUT COVERED ACTION (If different than State or Local Agency):

Proponent Name:

Address:

City, State, Zip:

C. OPEN MEETING LAWS

Agencies whose actions are not subject to open meeting laws (Bagley-Keene Open Meeting Act [Gov. Code sec 11120 et seq.] or the Brown Act [Gov. Code sec 54950 et seq.]) must post their draft certification on their website and in their office for public review and comment, and mail to all persons requesting notice (Administrative Procedures Governing Appeals, Rule 3). A state or local public agency that is subject to open meeting laws is encouraged to post the draft certification on their website and in the office for public review and comment and to mail to all persons requesting notice.

Any state or local public agency that is subject to open meeting laws with regard to its certification is also encouraged to take those actions. It is encouraged to upload any evidence that the project, plan or program went through for public review and comment as part of a Bagley-Keene or Brown Act meeting.

D. COVERED ACTION SUMMARY: (Project Description from approved CEQA document may be used here)

E. STATUS IN THE CEQA PROCESS:

F. STATE CLEARINGHOUSE NUMBER:(if applicable)

G. COVERED ACTION ESTIMATED TIME LINE:

ANTICIPATED START DATE: (If available)

ANTICIPATED END DATE: (If available)

H. COVERED ACTION TOTAL ESTIMATED PROJECT COST:

I. IF A CERTIFICATION OF CONSISTENCY FOR THIS COVERED ACTION WAS PREVIOUSLY SUBMITTED, LIST DSC REFERENCE NUMBER ASSIGNED TO THAT CERTIFICATION FORM:

J. Supporting Documents: