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TITLE: |
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DOCUMENT ID: |
8012
Appendix T1 Project/Activity Environmental Review Form (For New and/or Modified Projects/Activities) |
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SECTION 1: Information Gathering (Project Manager or SOTR to complete) |
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Project Manager: |
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Date |
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Project Name: |
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Type of Activity: (attach pictures, site
maps, and other information if available) |
Brief
Description or Comment |
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Design/Purchase and Installation/Operation of New Equipment |
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Removal or Repair of Existing Equipment |
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Implementation of New Activity or Process |
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Modification of Existing Activity or Process |
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Existing Activity or Process |
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Other Activity or Comment (Describe): |
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SECTION 2: Activity Schedule (Project Manager or SOTR to complete) |
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Anticipated Start Date: |
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Project Duration: |
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Anticipated Completion Date: |
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Air, Water, and Waste Information (complete as applicable) |
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Anticipated Air Emissions |
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Water-Based Project? |
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Yes |
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No |
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Source of Water for the
Project |
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How is water to be discharged or disposed (provide
estimated quantity): |
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Sanitary Sewer |
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Surface Water |
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Other Types of Waste Generated |
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Waste Disposal Plan (attach additional
information if necessary) |
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Special
Sanitary Sewer Discharge |
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Other
Waste Water |
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Hazardous
Waste |
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Solid
Waste (landfill or recycling) |
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Power/Natural Resource Consumption
Expected |
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Circle Yes or No for each of the items below and
describe in detail. |
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Yes No Chemicals
(oil, solvents, etc.) to be used (if yes, attach MSDS or reference
MSDS-online ID #s) |
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Yes No
Is an OSP required? (Attach completed THA and OSP) |
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Yes No
Potential for radioactive airborne emissions or effluents (if yes,
detail monitoring/controls approved by RadCon) |
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Yes No
Raw Material to be Used |
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Yes No
Subcontractor to be used |
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Forward Form to AD-ESH&Q |
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SECTION 3: Determination (AD-ESH&Q to complete) (When section 4 signed, Project
Manager/SOTR to communicate with staff, subcontractor/vendor, used about): |
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ES&H Policy Commitments: |
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Potential Significant Aspects: |
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TIPs Affected: |
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Emergency Response Procedure: |
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Follow-up Actions:(OSP,
MSDS, etc.?) |
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SECTION 4: Authorizations and Permits (EMS Management Representative Use Only) |
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Environmental Authorizations/Permits/Permit
Amendments Needed |
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EPCRA |
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Surface or Stormwater |
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RCRA |
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Air Issues |
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Industrial Waste Water (HRSD) |
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SPCC Notification |
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Air Issues |
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Other |
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Significant Environmental Impacts or Other
Information (describe) |
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Yes or No Can work
start prior to amendments? |
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SECTION 4: Signature (AD-ESH&Q to determine
responsible staff) |
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Responsible Staff Signature |
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Date |
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Responsible Staff Signature |
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Date |
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Project Manager/SOTR |
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Subject Matter Expert (if necessary) |
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Environmental Engineer |
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EMS Management Representative |
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ESH&Q Division Representative |
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Last signatory return form to Associate Director-ESH&Q Distribution Associate Director-ESH&Q Project
Manager/SOTR |
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