Adjacent Site Environmental Impact Assessment Questionnaire

Project Information

Project Name Project Location Assessment Date

Site Details

Description of Adjacent Site Current Use of Adjacent Site Distance from Project Site (meters)

Environmental Aspects

Does the adjacent site include sensitive ecosystems? Yes No Observed Flora and Fauna Are there water bodies nearby? Yes No Potential sources of pollution from adjacent site

Potential Impacts

Describe any potential impacts on the adjacent site Are mitigation strategies required? Yes No If yes, describe recommended mitigation measures

Additional Observations

Other comments or observations