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UPDATE ENVIRONMENTAL SURVEY REQUEST

A. UPDATE INFORMATION: Bio Cultural Special Waste

Submittal Date: (mm/dd/yyyy)

Sequence No:

B. REASON FOR SUBMITTAL: (Check all that apply)

In-Stream Work Stream Name:

Other:

DETAIL the above in the Additional Information field.

C. PROPOSED WORK: (for this update only)

Proposed Work: Highway Bridge Bike Trail Other

D. TREE REMOVAL?: Number?: or Acres

Existing Bridge(s) Structure Number: - , - , -

Historic District Involved? Historic Buildings Involved?

Section 4(f) Lands Involved? Section 6(f) Lands Involved?

E. FUNDING: Federal State TBP MFT Local Non-MFT

404 Permit Required Anticipated Processing:

F. LOCAL CONTACT PERSON: Telephone #: ( ) - ext.

Title: E-Mail:

G. ADDITIONAL INFORMATION: Memo By:

Page 2 - SPECIAL WASTE SCREEN

(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.)

Special Waste Submittal Date: mm/dd/yyyy

Step 1: Level 1 Screening Criteria

1. Acquisition of additional right-of-way or easements (temporary or permanent)

2. Railroad ROW (other than single rail rural ROW with no maintenance facilities)

3. Excavation or subsurface utility relocation

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.

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?

Environmental Condition	Minimum Search Distance	Database Search	Site Reconnaissance
Industrial and/or commercial property	0.25 miles
Other Environmental Conditions*	Property & adjoining property
(Please detail below.) *
State UST	Property & adjoining property
State LUST	0.5 miles
State Voluntary Cleanup, Brownfield, or landfills	0.5 miles
Federal NPL; NPL delisted, CERCLIS; CERCLIS NFRAP	1.0 miles; 0.5 miles; 0.5 miles;
	0.5 miles, respectively

Federal RCRA CORRACTS facilities; RCRA non-CORRACTS TSD facilities	1.0 miles; 0.5 miles, respectively
Federal RCRA generators list	Property & adjoining property
Federal RCRA Brownfield sites	0.5 miles
Federal ERNS System	Property

* 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:

2. Were photographs taken of the site and/or surrounding area?

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)

Google - type aerial maps	Extranet data	Historic Aerial Photos	Survey Books	Other Files & Photos
City Directories	County Assessor	Sanborn Fire Insurance Maps	Plat Books
Other source (describe):

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.

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:

Position:

Telephone #: ( )

Ext.

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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