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UPDATE ENVIRONMENTAL SURVEY REQUEST ADDENDUM
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A.
PROJECT INFORMATION:
Bio
Cultural
Special Waste |
| Submittal
Date:
(mm/dd/yyyy)Sequence
No:
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| B.
REASON FOR SUBMITTAL: (Check all that apply) |
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In-Stream Work
Stream Name:
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Other:
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| DETAIL
the above in the Additional Information field.
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C.
Existing Bridge(s) Structure Number:
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TREE REMOVAL?:
Number?:
or
Acres
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D.
LOCAL CONTACT PERSON:
Telephone #: (
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ext.
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Title:
E-Mail:
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E.
ADDITIONAL INFORMATION:
Memo
By:
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Page 2 - SPECIAL WASTE SCREEN
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(Note: This screening is required only for ESRs requesting Special Waste survey. For all
other survey types, proceed to end to submit form.
For questions about this form, please contact the District Special Waste Coordinator.)
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| Special
Waste Submittal Date:
mm/dd/yyyy |
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| Step
1: Level 1 Screening
Criteria |
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1.
Acquisition of additional right-of-way or easements (temporary or
permanent) |
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2.
Railroad ROW (other than single rail rural ROW with no maintenance
facilities)
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3.
Excavation or subsurface utility relocation |
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If
all responses are "No", sign below and place in the appropriate report.
The District Special Waste Coordinator may sign-off the project.
The Level 1
District Sign-off is valid for a maximum of six
months. However,
any projects answering "Yes" or "Don't Know" to #2 above are
not eligible for District
sign-off and must
go through the PESA process.
If any response is
"Yes" or "Don't Know", continue to Step 2: Level 2
Screening Criteria.
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| Step
2: Level 2 Screening
Criteria |
If for any reason, the presence of any environmental condition cannot be
determined from the site reconnaissance or from database searches,
please check this box, add an explanation below, and submit for PESA. |
| 1.
Does the project involve any of the following environmental conditions within the
corresponding minimum search distance? |
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Environmental
Condition |
Minimum
Search Distance |
Database Search |
Site Reconnaissance |
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Industrial and/or commercial property |
0.25 miles |
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Other Environmental Conditions* |
Property & adjoining property |
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(Please detail below.) * |
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State UST |
Property & adjoining property
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State LUST |
0.5 miles |
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State Voluntary Cleanup, Brownfield, or landfills |
0.5 miles |
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Federal NPL; NPL delisted, CERCLIS; CERCLIS NFRAP |
1.0 miles;
0.5 miles; 0.5 miles; |
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0.5 miles,
respectively |
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Federal RCRA CORRACTS facilities; RCRA non-CORRACTS TSD facilities |
1.0 miles;
0.5 miles, respectively |
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Federal RCRA generators list |
Property & adjoining property |
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Federal RCRA Brownfield sites |
0.5 miles |
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Federal ERNS System |
Property |
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* Other Environmental Conditions are identified through site
reconnaissance and include situations that may negatively affect the
property including the
presence of, for example, illegal dumping, unknown containers, waste
associated with "crack" or methamphetamine houses (i.e., discarded
hazardous
material
on the outside of a property), battery piles, paint spills, abandoned transformers,
surface staining, vegetative damage, etc. |
* Describe Findings/Other
Environmental
Conditions:
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2. Were photographs taken of the site and/or surrounding area?
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In an effort to identify any property or condition that may
negatively affect the project site or potential historical, industrial
and/or
commercial
use, the following sources of information can be helpful while screening
the project. |
| 3.
Place a check next to each reference that is reviewed.
(Optional) |
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If any historical
reference indicates the possible presence of a property or condition
that may negatively affect the project site, then a PESA is required. |
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If
all responses for database search and site reconnaissance are "No",
then the District Special Waste Coordinator may sign-off the
project.
The Level 2 District Sign-off is valid for a maximum six months.
If
any response for database search and
site
reconnaissance is "Yes", or
if a database search or site reconnaissance is not performed or is
inconclusive, then a PESA is
required. |
| Conducted
By:
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| Position:
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| Telephone
#: (
)
-
Ext.
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After
this Level 2 District Sign-Off has been completed, please email a
screen shot of the form to the Central Office, BDE, Environment Section,
Geologic & Waste Assessment Unit for
processing. |
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