TITLE:

ES&H Manual

 

DOCUMENT ID:

8012 Appendix T1

Project/Activity Environmental Review Form

 (For New and/or Modified Projects/Activities)

 

 

 

 

 

SECTION 1:  Information Gathering (Project Manager or SOTR to complete)

Project Manager:

 

Date

 

Project Name:

 

Type of Activity:

(attach pictures, site maps, and other information if available)

Brief Description or Comment

 

Design/Purchase and Installation/Operation of New Equipment

 

 

Removal or Repair of Existing Equipment

 

 

Implementation of New Activity or Process

 

 

Modification of Existing Activity or Process

 

 

Existing Activity or Process

 

 

Other Activity or Comment (Describe):

SECTION 2: Activity Schedule (Project Manager or SOTR to complete)

Anticipated Start Date:

 

Project Duration:

 

Anticipated Completion Date:

 

 

Air, Water, and Waste Information (complete as applicable)

Anticipated Air Emissions

 

Water-Based Project?

 

Yes

 

No

 

Source of Water for the Project

 

How is water to be discharged or disposed (provide estimated quantity):

Sanitary Sewer

 

Surface Water

 

Other Types of Waste Generated

 

Waste Disposal Plan (attach additional information if necessary)

Special Sanitary Sewer Discharge

 

Other Waste Water

 

Hazardous Waste

 

Solid Waste (landfill or recycling)

 

Power/Natural Resource Consumption Expected

 

 

 


 

 

 

 

Circle Yes or No for each of the items below and describe in detail.

Yes   No   Chemicals (oil, solvents, etc.) to be used (if yes, attach MSDS or reference MSDS-online ID #s)

Yes   No    Is an OSP required? (Attach completed THA and OSP)

Yes   No    Potential for radioactive airborne emissions or effluents (if yes, detail monitoring/controls approved by RadCon)

Yes   No    Raw Material to be Used

Yes   No    Subcontractor to be used

Forward Form to AD-ESH&Q

SECTION 3:  Determination (AD-ESH&Q to complete)

(When section 4 signed, Project Manager/SOTR to communicate with staff, subcontractor/vendor, used about):

ES&H Policy Commitments:

 

Potential Significant Aspects:

 

TIPs Affected:

 

Emergency Response Procedure:

 

Follow-up Actions:(OSP, MSDS, etc.?)

 

 

 


 

 

 

 

SECTION 4:  Authorizations and Permits (EMS Management Representative Use Only)

Environmental Authorizations/Permits/Permit Amendments Needed

 

EPCRA

 

Surface or Stormwater

 

RCRA

 

Air Issues

 

Industrial Waste Water (HRSD)

 

SPCC Notification

 

Air Issues

 

Other

Significant Environmental Impacts or Other Information (describe)

Yes or No            Can work start prior to amendments?

SECTION 4:  Signature (AD-ESH&Q to determine responsible staff)

Responsible Staff Signature

 

Date

 

Responsible Staff Signature

 

Date

 

 

 

 

 

 

 

Project Manager/SOTR

 

 

 

Subject Matter Expert (if necessary)

 

 

 

 

 

 

 

 

 

Environmental Engineer

 

 

 

EMS Management Representative

 

 

 

 

 

 

 

 

 

ESH&Q Division Representative

 

 

 

 

 

 

 

Last signatory return form to Associate Director-ESH&Q

Distribution  Associate Director-ESH&Q

                     Project Manager/SOTR