TITLE:

ES&H Manual

 

DOCUMENT ID:

8012 Appendix T1

Proposed Construction Activity Information Checklist

 

 

 

 

 

PROPOSED ACTION TITLE:

 

 

 

 

 

NEPA Action Managers:

 

 

 

 

NEPA Action Funding:

 

 

 

 

Total Estimated Cost:

 

 

 

 

Estimated Activity Start Date:

 

 

 

 

Information Compiled by:

 

 

 

 

 

 

 

GENERAL INFORMATION:     

 

 

Are the actions described part or parts of an ongoing EA or other NEPA activity?

 

 

Yes        No

Explain:

 

 

 

Are any extraordinary circumstances related to these actions?

 

 

Yes        No

Explain:

 

 

 

Are actions connected to other actions with potentially significant impacts?

 

 

Yes        No

Explain:

 

 

 

Location for the Proposed Action:

 

 

 

 

 

 

 

 

DESCRIPTION OF THE PROPOSED ACTION

 

 

Provide a narrative description of the physical activities involved in setting up and/or performing the proposed activities.  Include construction and operations and primary equipment to be used. Address timeframes.

Describe the magnitude of the activity.

Provide as much quantitative information as possible relevant to the overall impact of the project on the environment

 

 

 

 

Activities (sample)

  1. Installation of Erosion and Control measures as necessary.
  2. Removal of asphalt
  3. Excavation of foundations
  4. Concrete work
  5. Erection of building
  6. Removal of all debris to off site location
  7. Jefferson Lab use of building for storing lead

 

 

JUSTIFICATION AND NEED FOR THE PROPOSED ACTION/PROJECT

 

 

What problem is this action intended to solve, and how will this action solve it?

What alternative solutions to this particular problem exist?  Are there different technologies or techniques that could also solve the problem?  If so, why were they rejected?

Were alternative sites for this project considered?  If so, why were they rejected?

What would be the consequence(s) of taking NO ACTION toward the problem?

 

 

 

 

DESCRIPTION OF THE AFFECTED ENVIRONMENT AND SAFETY AND HEALTH ISSUES

 

 

Would any part of this activity involve work outside existing buildings?

If YES, provide a general description of the affected area and the geographic location.  Indicate the entire extent of the project on the appropriate map.

Has the affected area ever been used as a chemical dispensing area, waste or product storage area, or been the site of any chemical spills?  If so, describe.

Consider below ground effects, surface effects, and above ground effects.

 

 

 

 


 

 

 

 

 

POTENTIAL ENVIRONMENTAL EFFECTS CHECKLIST

[Consider all activities that will be part of or necessary in support of this project.  Include work to be performed by subcontractors.]

 

 

1.       ACTIVITY:  The primary and related activities for this project would be:

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Indoor Bench-Scale Research

 

 

 

 

 

 

Indoor Pilot-Scale Research

 

 

 

 

 

 

Outdoor Research

 

 

 

 

 

 

Technology Development

 

 

 

 

 

 

Technology Demonstration

 

 

 

 

 

 

Chemical/Physical Analysis

 

 

 

 

 

 

Maintenance/Modification

 

 

 

 

 

 

Fabrication

 

 

 

 

 

 

Production

 

 

 

 

 

 

Routine Operation

 

 

 

 

 

 

Non-routine Operation

 

 

 

 

 

 

Renovation Indoors

 

 

 

 

 

 

New Construction

 

 

 

 

 

 

Transportation On-site

 

 

 

 

 

 

Transportation Off Site

 

 

 

 

 

 

Clearing/Removal of Vegetation

 

 

 

 

 

 

Other

 

 

 

 


 

 

 

 

2.      INDUSTRIAL SAFETY: 

         Would activities (during construction or during operations) involve any of the following:

 

 

            Yes               No              Uncertain 

 

 

Explain: 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Excavation/Trenching/Clearing [indicate total area affected]

 

 

 

 

 

 

Utilities Lockout/Tagout

 

 

 

 

 

 

Crane Operations

 

 

 

 

 

 

Welding/Cutting

 

 

 

 

 

 

Confined Space Entry

 

 

 

 

 

 

Blocking Roads

 

 

 

 

 

 

Use of Scaffolds

 

 

 

 

 

 

Use of Fall Protection

 

 

 

 

 

 

Use of Explosives

 

 

 

 

 

 

Use of Corrosives

 

 

 

 

 

 

Use of Incompatible Chemicals

 

 

 

 

 

 

Use of Compressed Gas Cylinders

 

 

 

 

 

 

High Operating Pressures

 

 

 

 

 

 

X-Rays

 

 

 

 

 

 

Radiation Protection

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

3.       INDUSTRIAL HYGIENE PROTECTION:

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

High Noise Level

 

 

 

 

 

 

Extreme Temperature

 

 

 

 

 

 

Non-ionizing Radiation

 

 

 

 

 

 

Ionizing Radiation [refer to #10]

 

 

 

 

 

 

Ergonomic Situations

 

 

 

 

 

 

Respirator or Other Air Purifying Device

 

 

 

 

 

 

Anti-contamination Protective Clothes

 

 

 

 

 

 

Confined Space

 

 

 

 

 

 

Sanitation

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

4.       RESPIRATORY PROTECTION:

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Abrasive Blasting

 

 

 

 

 

 

Acid or Alkali Cleaning of Metals

 

 

 

 

 

 

Degreasing

 

 

 

 

 

 

Decontamination

 

 

 

 

 

 

Use of Coolant and Cutting Fluids

 

 

 

 

 

 

Welding, Cutting, or Brazing

 

 

 

 

 

 

Grinding, Polishing, or Brazing

 

 

 

 

 

 

Metal Thermal Spraying

 

 

 

 

 

 

Painting

 

 

 

 

 

 

Electroplating

 

 

 

 

 

 

Heat Treatment of Metal Alloys

 

 

 

 

 

 

Boiler Deslagging

 

 

 

 

 

 

Furnaces

 

 

 

 

 

 

Hoods

 

 

 

 

 

 

Respirator or Other Air Purifying Devices

 

 

 

 

 

 

Other, including work with radioactive materials

 

 

 

 

 

 

 

 

5.       MATERIALS:  Would any of the following be encountered (E), handled (H), stored (S), or used (U) or disposed (D) during any phase of the project?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Fissionable Materials

 

 

 

 

 

 

Radioactive Materials

 

 

 

 

 

 

Hazardous Materials

 

 

 

 

 

 

Mixed Materials (Haz & Rad)

 

 

 

 

 

 

Toxic Materials

 

 

 

 

 

 

PCBs

 

 

 

 

 

 

Oils

 

 

 

 

 

 

Asbestos

 

 

 

 

 

 

Fibrous Insulation

 

 

 

 

 

 

Organic Chemicals

 

 

 

 

 

 

Heavy Metals

 

 

 

 

 

 

Compressed Gases

 

 

 

 

 

 

Pesticides/Herbicides

 

 

 

 

 

 

Petroleum

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

6.       EQUIPMENT:  Would any of the following types of oil-containing equipment be used during any phase of the project?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Transformers

 

 

 

 

 

 

Capacitors

 

 

 

 

 

 

Hydraulic Presses

 

 

 

 

 

 

Other Hydraulic Equipment

 

 

 

 

 

 

Large Light Ballasts

 

 

 

 

 

 

Vacuum Pumps

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

7.       LIQUID WASTES:  Would the project involve disposal or discharge of liquid wastes into any collection and/or treatment systems?  What and how much?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Sanitary Wastewater

 

 

 

 

 

 

Low-Level Rad Waste

 

 

 

 

 

 

Process Waste

 

 

 

 

 

 

Other Liquid Waste, e.g. sump discharges

 

 

 

 

 

 

Discharge to Soil

 

 

 

 

 

 

Storm Sewer / Surface Water

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

8.       SINKS/DRAINS:  would any of the following be present in the project area?  What and how much?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Sinks

 

 

 

 

 

 

Sumps

 

 

 

 

 

 

Floor Drains

 

 

 

 

 

 

Fume Hood Drains

 

 

 

 

 

 

Storm Drains

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

9.       SOLID WASTES:  Would solid wastes be generated (G), stored (S), or disposed (D) of as a result of this project?  What, how much, and characteristics, if known?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Asbestos

 

 

 

 

 

 

Radioactive

 

 

 

 

 

 

RCRA Hazardous

 

 

 

 

 

 

Mixed

 

 

 

 

 

 

Non-hazardous

 

 

 

 

 

 

Radioactively Contaminated Wipes

 

 

 

 

 

 

Contaminated Wipes

 

 

 

 

 

 

Biohazard Wastes

 

 

 

 

 

 

Oily Wastes

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

10.    AIRBORNE EMISSIONS:  Would the project generate airborne emissions?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Radioactive [provide dose levels to workers/public]

 

 

 

 

 

 

Hazardous or Toxic

 

 

 

 

 

 

Mixed

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

11.    POLLUTION PREVENTION (P2):  Would any of the following waste minimization & P2 methods be applicable and considered for use for the proposed project?

 

 

Yes

No

Unc

Activity (Accel. & Physics Div practices)

Explanation

 

 

 

 

 

P2 Practices

 

 

 

 

 

 

Waste Volume Reduction

 

 

 

 

 

 

Waste Toxicity Reduction

 

 

 

 

 

 

Waste Segregation

 

 

 

 

 

 

Equipment Reuse

 

 

 

 

 

 

Materials Recycling

 

 

 

 

 

 

Product/Materials Substitution

 

 

 

 

 

 

Inventory Control

 

 

 

 

 

 

Energy Conservation

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

12.    OUTDOOR STORAGE:  Would the project utilize tank, drum, bottle, or other storage materials?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Radioactive

 

 

 

 

 

 

Hazardous or Toxic

 

 

 

 

 

 

Mixed

 

 

 

 

 

 

Flammable Materials

 

 

 

 

 

 

Reactive Materials

 

 

 

 

 

 

Corrosive Materials

 

 

 

 

 

 

Explosive Materials

 

 

 

 

 

 

Shelf Chemicals

 

 

 

 

 

 

Old Chemicals

 

 

 

 

 

 

Oil

 

 

 

 

 

 

Pesticides/Herbicides

 

 

 

 

 

 

Petroleum

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

13.    CHEMICAL OR BIOLOGICAL AGENT USE:  Will this project result in the storage and/or use of chemicals or biochemical agents in the workplace?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Explain: 

 

 

Activity

Chemical & Quantity

Storage Method

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.    ACCUMULATION, TREATMENT, OR RECYCLE AREAS:  Would the project involve any of the following?  Describe and quantify.

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

RCRA Satellite Areas

 

 

 

 

 

 

RCRA Central Accumulation Area

 

 

 

 

 

 

Laundry Recycle

 

 

 

 

 

 

Radioactive Material Storage

 

 

 

 

 

 

Radioactive Waste Storage

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

15.    BELOW GROUND STORAGE:  Would the project utilize ground equipment or tanks for storage, control, or transport of materials?

            Yes               No              Uncertain              Not Applicable 

 

 

 

 

 

 

16.    RADIOLOGICAL AREAS:  Would the project be performed in any of the following radiological areas?  Indicate locations, if appropriate.

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Low-Level Radiation Source Area

 

 

 

 

 

 

High Radiation Area

 

 

 

 

 

 

Regulated Area

 

 

 

 

 

 

Airborne Activity Area

 

 

 

 

 

 

Radiation Area

 

 

 

 

 

 

Very High Radiation Area

 

 

 

 

 

 

Contamination Area

 

 

 

 

 

 

Respirator Area

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

17.    RADIATION PROTECTION CONTROLS:  Would any of the following protective or administrative controls be involved with the project?  Will the project result in any exposure of workers or the public to radiation?  If so, indicate dose levels.

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Radiation Work Permit

 

 

 

 

 

 

Radiation Worker Training

 

 

 

 

 

 

Respirator or Other Air Purifying Device

 

 

 

 

 

 

Anti-contamination Protective Clothes

 

 

 

 

 

 

Supplementary Dosimetry

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

18.    RADIATION SOURCES:  Would the project involve the use or storage of any radiation sources?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

X-Ray Machine / Generator

 

 

 

 

 

 

Sealed Radioactive Material

 

 

 

 

 

 

Accelerator

 

 

 

 

 

 

Unsealed Radioactive Material

 

 

 

 

 

 

Ultraviolet Light Sources

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

19.    OPERATIONAL READINESS:  Would the activity involve one or more of the following?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Safety Review

 

 

 

 

 

 

Safety Class Items

 

 

 

 

 

 

Items under Configuration Control

 

 

 

 

 

 

Glove Boxes

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

20.    UNCONTROLLED RELEASES:  Would measures be in place to manage possible uncontrolled emissions, discharge, or spills during any phase of the project?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Explain: 

 

 

 

 

 

 

 

 

 

21.    EMERGENCY RESPONSE:  In the event of a release, would the following be readily available in the work area?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

MSDS Information

 

 

 

 

 

 

Spill Control and Containment Materials

 

 

 

 

 

 

Phone numbers

 

 

 

 

 

 

Portable Fire Extinguishers

 

 

 

 

 

 

Warning Signs

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

22.    PERMITTING:  Would the project/activity require application for or modification of any of the following permits?

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Excavation/Penetration

 

 

 

 

 

 

Burning Permit

 

 

 

 

 

 

Radiation Work Permit

 

 

 

 

 

 

Safety Work Procedure

 

 

 

 

 

 

Air Permit

 

 

 

 

 

 

Fugitive Emissions Permit

 

 

 

 

 

 

Existing VPDES Permit

 

 

 

 

 

 

Permit for Groundwater Dewatering

 

 

 

 

 

 

RCRA

 

 

 

 

 

 

Corps of Engineers

 

 

 

 

 

 

NESHAPs

 

 

 

 

 

 

Stormwater Management

 

 

 

 

 

 

Stormwater During Construction Activities

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

23.    GROUNDWATER PROTECTION:  Does the proposed project have any of the following existing or planned features or conditions?  Will this project result in any activation of soil or groundwater?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Yes

No

Unc

Activity

Explanation

 

 

 

 

 

Existing Wells or Boreholes

 

 

 

 

 

 

Existing Contaminated Groundwater

 

 

 

 

 

 

Excavations requiring Dewatering during Construction

 

 

 

 

 

 

Devices that could alter Groundwater Levels

 

 

 

 

 

 

New Monitoring Wells

 

 

 

 

 

 

New Soil Borings

 

 

 

 

 

 

 

24.    PLANT/ANIMAL SPECIES:  Has the project area been surveyed for plants (or habitats of plants) or animals (or habitats) listed as follows?

 

 

            Yes               No              Uncertain              Not Applicable  

 

 

Explain: 

 

 

 

 

 

 

 

 

 

25.   AQUATIC SPECIES:  Have waters in the project area been surveyed for aquatic species listed as follows?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

 

 

 

 

 

26.    HISTORICAL/ARCHEOLOGICAL:  Has the proposed site been surveyed for objects of historical/archeological significance?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Explain: 

 

 

 

 

 

 

 

 

 

27.    FLOODPLAIN:  Would the project encroach upon or take place within a floodplain?

 

 

            Yes               No              Uncertain              Not Applicable 

 

 

Explain: 

 

 

 

 

 

 

 

 

 

28.  WETLANDS:  Are the following conditions present at any proposed site?

Note:  Wetlands are not limited to standing water.  Areas such as forest, sedge meadows, and stream banks may qualify.

 

 

            Yes               No              Uncertain