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ENVIRONMENTAL SURVEY REQUEST
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A.
PROJECT INFORMATION:
Bio
Cultural
Special Waste |
| Submittal
Date:
(mm/dd/yyyy)
Requesting Agency:
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| Contract
#:
Job No.:
-
-
PPS Project
No.:
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| District:
Counties:
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| Route:
Marked:
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| Street:
Section:
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| Municipality(ies):
Project
Length:
Miles |
| From
To (At):
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| Quadrangle:
Township-Range-Section:
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| Anticipated
Design Approval:
(mm/dd/yyyy) |
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B.
REASON FOR SUBMITTAL: (Check all that apply) |
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Acquisition of additional ROW or easement
acres |
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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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The Additional Information field on this form should be used to expand
on the Project Description. |
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C.
PROJECT DESCRIPTION: |
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Proposed Work:
Highway
Bridge
Bike Trail
Other
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D.
TREE REMOVAL?:
Number?:
or
Acres |
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Existing Bridge(s) Structure Number:
-
,
-
,
-
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Historic District Involved?
Historic
Buildings Involved?
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Section 4(f) Lands Involved?
Section 6(f)
Lands Involved?
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E.
FUNDING:
Federal
State
TBP
MFT
Local Non-MFT |
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404 Permit Required
Anticipated Processing:
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F.
LOCAL CONTACT PERSON:
Telephone #:
(
)
-
ext.
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Title:
E-Mail:
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G.
ADDITIONAL INFORMATION:
Memo
By:
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Page 2 - SPECIAL WASTE SCREEN
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| Special
Waste Submittal Date:
mm/dd/yyyy
Date of Preliminary Report:
mm/dd/yyyy |
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| Screening
Criteria |
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Railroad ROW
(except single rail rural, with no maintenance facilities, evidence or
open |
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dumping or record of spills in the project area) |
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Building
Demolition/Modification
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SubSurface
Utility Relocation or Linear Excavation |
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If
all responses are No, sign and place in appropriate report. If any
response is Yes or Don't Know, continue
screening or
survey project as necessary.
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Any known
hazardous or non-hazardous waste sites in vicinity (CERCLIS[1.0 mile], |
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Description:
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Land Use
History and Development Setting
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Entirely
Agricultural/Residential or with some recently developed commercially
benign uses (see list |
| of
potentially non benign commercial uses) |
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State
Highest Level of Development
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Current
Land Uses
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Previous
Land Uses
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Adjacent
Land Uses
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Records
Review:
In-House
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Old Plat Books
Soil Survey
Old Aerial Photos
Old Survey Books
Other Dist. Files Photos |
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Other Sources |
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City Directories
County Assessor
Fire Dept.
Sanborn Maps
Other
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Take
Photos of sites or attach sketch. If land use is and was always entirely
Agriculture/Residential or has some
recently developed commercially benign uses, continue screen;
otherwise submit for survey. |
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| Visual
Inspection Inspection
Date:
mm/dd/yyyy |
| STEP
1 |
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Underground
Tanks |
| Building
or building materials containing regulated substances other than
asbestos:
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Buildings
Batteries Solvents
Foundry Sands Transformers
or Other Oil filled Paint
Lead
Electrical
Equipment
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| STEP
2 |
| Surface
Tanks Sumps Ponds
Drums Basins
Landfills |
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Transformers
(except pole mounted with no discernable evidence of soil staining) |
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RR Signal
Boxes (except those with no discernable soil staining) |
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Other (storage
structures/pipelines [except water and natural gas]) |
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STEP
3
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| Surface
Staining Oil
Sheen Odors
Vegetation
Damage Other
(spills, leaks, illegal dumping, etc.) |
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If
entirely Agriculture/Residential or has some recently developed
commercial benign uses, and if all responses to
Step 1, Step2,
and Step 3 are No, sign form and place in appropriate report, otherwise
send for Preliminary
Environmental
Site Assessment (PESA). |
| Conducted
By:
Title:
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| Telephone
#: (
)
-
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