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Reference #18.eb263e17.1764556805.53bb16cd

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ENVIRONMENTAL SURVEY REQUEST

Prior to preparing and submitting this ESR, the user should carefully read the instructions, and associated IDOT policy (BDE Manual Chapter 27 & Local Roads Manual Chapter 20).

Submittal of the ESR initiates the Phase I environmental survey process, which takes a minimum of 6 months to complete. Results of the environmental surveys must be completed in advance of the desired construction letting.

All fields must be completed unless the information is unavailable at the time of submittal or not applicable to the project. If the District and Requesting Entity fields are filled out incorrectly, the ESR will not be submitted to the appropriate person.

A. PROJECT INFORMATION:

Biological

Cultural

State ROW Special Waste

Submittal Date: (mm/dd/yyyy)

Requesting Entity:

Contract #:

Job No.: - -

PPS Project No.:

Section No.:

or Project Identifier:
(for CREATE Projects Only)

District:

County(ies):

Route:

Marked:

Street:

Project Length: Miles

Municipality(ies):

Township-Range-Section:

Quadrangle:

From To (At):

Survey Completion Target Date: (mm/dd/yyyy)
(Six months minimum required)

Anticipated Design Approval Date: (mm/dd/yyyy)

Anticipated NEPA Processing:

B. REASON(S) FOR SUBMITTAL: (Check all that apply; includes Special Waste Level 1 Screening Criteria)

Survey Types: B = Biological; C = Cultural; SW = Special Waste

B,C Involves acquisition of additional ROW or temporary or permanent easements. acres

SW Crosses or involves RR Row on a state-maintained route.

B,C Requires in-stream work (e.g., drainage structure runaround). Stream Name:

C Potential to affect a historic district or historic property.

C Involves replacement or rehabilitation of a bridge/culvert 40 years old or older.

SW Involves acquisition of State ROW; involves excavation on State ROW, or involves subsurface utility relocation on State ROW.

Other

Biological

Cultural

State ROW Special Waste (ensure these checked boxes match with those above)

C. PROJECT DESCRIPTION: [255 character limit. If needed, use "Addl. Info" Memo to expand on this description.]

Proposed Work:

Roadway

Bridge

Railroad

Airport

Other

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?

D. FUNDING & PERMITTING:

404 Permit Required

E. PROJECT CONTACT PERSON

Name:

Telephone #: ( ) - ext.

Title/Organization:

E-Mail:

ADDITIONAL INFORMATION

Memo By:

Page 2 - SPECIAL WASTE LEVEL II SCREENING

If the Special Waste box is checked in Section B above based on the type of work involved with the project, then Level 1 special waste screening fails and a PESA is required. Submitting this ESR initiates the PESA process. Optionally, you may proceed with a Level 2 special waste screening.

According to IDOT Policy, "due care" must be performed to determine whether regulated substances may be present on or adjoining a project. A PESA is IDOT's chosen initial and minimum method of demonstrating "due care". Thus, a PESA is required on every project where the Special Waste box is checked.

There are some select scenarios where the need for a PESA can be avoided and "due care" demonstrated based on the successful performance and documentation of a Level II Screening. The Level II Screening criteria have been carefully constructed and apply in project situations that are likely to pose minimal risk. If any response to Level 2 Screening questions in 2A below is "yes" or is undetermined, then a PESA is required.

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

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.

2A. 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 (Please detail below.)¹	Property & adjoining property
Crosses or otherwise involves railroad ROW (Please detail below.)²	Property & adjoining property
State UST	Property & adjoining property
State LUST	0.5 miles
State Voluntary Cleanup, Brownfield, or landfills	0.5 miles
Federal NPL; NPL delisted, SEMS; SEMS 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

¹ Other Environmental Conditions are identified through in-person 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. Historic land uses that include any of these activities also qualify.

² Crosses or otherwise involves railroad ROW, other than a single rail rural ROW with no maintenance facilities.

Describe Findings/Other Environmental Conditions: 2B. Were photographs taken of the site and/or surrounding area?

2C. Place a check next to each reference that is reviewed. (Optional)

To identify a 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.

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 and site reconnaissance are conclusively “No”, then the Level II screening is successful and the District Special Waste Coordinator may sign-off the project. Ensure the “Special Waste” box in Section A is checked.

For local roads projects, the local public agency (LPA) shall complete the Level 2 Screening form for portions of the project affecting State right-of-way. The District Special Waste Coordinator must confirm the screening results and shall replace the LPA information in the sign-off box with their own information prior to submittal to BDE.

The Level II District Sign-off is valid for up to six months. After that, the District Sign-Off must be validated for the project to achieve design approval and ultimately cleared for letting. 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. See BDE Manual 27-3 for additional instructions.

Special Waste Screen Preparation Date:

Prepared By (name):

Organization/firm:

Telephone #: ( ) -

Ext.

Email:

On behalf of (project developer):

Other Information: