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State of California — The Resources Agency <br />DEPARTMENT OF PARKS AND RECREATION <br />CEQA Compliance Certification Form <br />GRANTEE: <br />Project Name: <br />Project Address: <br />Is CEQA complete? ❑Yes ONO Is completing CEQA a PROJECT SCOPE item? ❑Yes ❑No <br />What document was filed, or is expected to be filed for this project's CEQA analysis: <br />Date complete/expected to be completed: <br />❑ Notice of Exemption (attach recorded copy if filed) <br />❑ Notice of Determination (attach recorded copy if filed) <br />❑ Other: <br />If CEQA is complete, and a Notice of Exemption or Notice of Determination was not filed, attach <br />a letter from the Lead Agency explaining why, certifying the project has complied with CEQA <br />and noting the date that the project was approved by the Lead Agency. <br />Lead Agency Contact Information <br />Agency Name: <br />Contact Person: <br />Mailing Address: <br />Phone: ( ) Email: <br />Certification: <br />I hereby certify that the above referenced Lead Agency has complied or will comply with the <br />California Environmental Quality Act (CEQA) and that the project is described in adequate and <br />sufficient detail to allow the project's construction or acquisition. <br />I further certify that the CEQA analysis for this project encompasses all aspects of the work to <br />be completed with grant funds. <br />AUTHORIZED REPRESENTATIVE Signature <br />Print Name and Title <br />FOR OGALS USE ONLY <br />CEQA Document Date Received PO Initials <br />❑NOE ❑NOD <br />Date <br />15 <br />