ES&H Manual



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:




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?






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




Surface or Stormwater




Air Issues


Industrial Waste Water (HRSD)


SPCC Notification


Air Issues



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




Responsible Staff Signature










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