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TITLE: |
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DOCUMENT ID: |
8012
Appendix T1 Proposed Construction Activity Information
Checklist |
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PROPOSED ACTION TITLE: |
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NEPA Action
Managers: |
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NEPA Action Funding: |
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Total Estimated Cost: |
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Estimated Activity Start
Date: |
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Information Compiled by: |
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GENERAL INFORMATION: |
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Are the actions described part or parts of an
ongoing EA or other NEPA activity? |
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Yes No |
Explain: |
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Are any extraordinary circumstances related to these
actions? |
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Yes No |
Explain: |
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Are actions connected to other actions with
potentially significant impacts? |
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Yes No |
Explain: |
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Location for the Proposed Action: |
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DESCRIPTION
OF THE PROPOSED ACTION |
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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 |
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Activities (sample)
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JUSTIFICATION AND NEED FOR THE
PROPOSED ACTION/PROJECT |
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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? |
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DESCRIPTION
OF THE AFFECTED ENVIRONMENT AND SAFETY AND HEALTH ISSUES |
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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. |
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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.] |
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1. ACTIVITY: The primary and related activities for
this project would be: |
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Yes |
No |
Unc |
Activity |
Explanation |
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Indoor Bench-Scale Research |
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Indoor Pilot-Scale Research |
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Outdoor Research |
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Technology Development |
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Technology Demonstration |
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Chemical/Physical Analysis |
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Maintenance/Modification |
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Fabrication |
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Production |
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Routine Operation |
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Non-routine Operation |
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Renovation Indoors |
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New Construction |
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Transportation On-site |
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Transportation Off Site |
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Clearing/Removal of Vegetation |
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Other |
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2. INDUSTRIAL
SAFETY: Would
activities (during construction or during operations) involve any of the
following: |
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Yes No Uncertain |
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Explain: |
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Yes |
No |
Unc |
Activity |
Explanation |
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Excavation/Trenching/Clearing [indicate total area
affected] |
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Utilities Lockout/Tagout |
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Crane Operations |
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Welding/Cutting |
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Confined Space Entry |
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Blocking Roads |
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Use of Scaffolds |
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Use of Fall Protection |
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Use of Explosives |
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Use of Corrosives |
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Use of Incompatible Chemicals |
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Use of Compressed Gas Cylinders |
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High Operating Pressures |
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X-Rays |
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Radiation Protection |
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Other |
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3. INDUSTRIAL
HYGIENE PROTECTION: |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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High Noise Level |
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Extreme Temperature |
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Non-ionizing Radiation |
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Ionizing Radiation [refer to
#10] |
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Ergonomic Situations |
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Respirator or Other Air Purifying Device |
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Anti-contamination Protective Clothes |
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Confined Space |
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Sanitation |
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Other |
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4. RESPIRATORY
PROTECTION: |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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Abrasive Blasting |
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Acid or Alkali Cleaning of Metals |
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Degreasing |
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Decontamination |
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Use of Coolant and Cutting Fluids |
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Welding, Cutting, or Brazing |
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Grinding, Polishing, or Brazing |
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Metal Thermal Spraying |
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Painting |
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Electroplating |
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Heat Treatment of Metal Alloys |
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Boiler Deslagging |
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Furnaces |
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Hoods |
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Respirator or Other Air Purifying Devices |
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Other, including work with radioactive materials |
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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? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Fissionable Materials |
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Radioactive Materials |
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Hazardous Materials |
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Mixed Materials (Haz & Rad) |
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Toxic Materials |
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PCBs |
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Oils |
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Asbestos |
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Fibrous Insulation |
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Organic Chemicals |
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Heavy Metals |
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Compressed Gases |
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Pesticides/Herbicides |
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Petroleum |
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Other |
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6. EQUIPMENT: Would any of the following types of
oil-containing equipment be used during any phase of the project? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Transformers |
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Capacitors |
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Hydraulic Presses |
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Other Hydraulic Equipment |
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Large Light Ballasts |
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Vacuum Pumps |
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Other |
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7. LIQUID
WASTES: Would the project involve
disposal or discharge of liquid wastes into any collection and/or treatment
systems? What and how much? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Sanitary Wastewater |
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Low-Level Rad Waste |
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Process Waste |
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Other Liquid Waste, e.g. sump discharges |
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Discharge to Soil |
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Storm Sewer / Surface Water |
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Other |
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8. SINKS/DRAINS: would any of the following be present in
the project area? What and how much? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Sinks |
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Sumps |
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Floor Drains |
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Fume Hood Drains |
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Storm Drains |
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Other |
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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? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Asbestos |
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Radioactive |
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RCRA Hazardous |
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Mixed |
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Non-hazardous |
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Radioactively Contaminated Wipes |
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Contaminated Wipes |
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Biohazard Wastes |
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Oily Wastes |
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Other |
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10. AIRBORNE
EMISSIONS: Would the project generate
airborne emissions? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Radioactive [provide dose levels to
workers/public] |
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Hazardous or Toxic |
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Mixed |
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Other |
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11. POLLUTION
PREVENTION (P2): Would any of the
following waste minimization & P2 methods be applicable and considered
for use for the proposed project? |
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Yes |
No |
Unc |
Activity (Accel. & Physics Div
practices) |
Explanation |
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P2 Practices |
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Waste Volume Reduction |
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Waste Toxicity Reduction |
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Waste Segregation |
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Equipment Reuse |
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Materials Recycling |
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Product/Materials Substitution |
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Inventory Control |
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Energy Conservation |
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Other |
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12. OUTDOOR
STORAGE: Would the project utilize
tank, drum, bottle, or other storage materials? |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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Radioactive |
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Hazardous or Toxic |
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Mixed |
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Flammable Materials |
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Reactive Materials |
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Corrosive Materials |
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Explosive Materials |
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Shelf Chemicals |
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Old Chemicals |
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Oil |
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Pesticides/Herbicides |
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Petroleum |
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Other |
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13. CHEMICAL
OR BIOLOGICAL AGENT USE: Will this
project result in the storage and/or use of chemicals or biochemical agents
in the workplace? |
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Yes No Uncertain Not Applicable |
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Explain: |
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Activity |
Chemical
& Quantity |
Storage
Method |
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14. ACCUMULATION,
TREATMENT, OR RECYCLE AREAS: Would
the project involve any of the following?
Describe and quantify. |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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RCRA Satellite Areas |
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RCRA Central Accumulation Area |
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Laundry Recycle |
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Radioactive Material Storage |
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Radioactive Waste Storage |
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Other |
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15. BELOW
GROUND STORAGE: Would the project
utilize ground equipment or tanks for storage, control, or transport of
materials? |
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Yes No Uncertain Not
Applicable |
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16. RADIOLOGICAL
AREAS: Would the project be performed
in any of the following radiological areas?
Indicate locations, if appropriate. |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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Low-Level Radiation Source Area |
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High Radiation Area |
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Regulated Area |
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Airborne Activity Area |
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Radiation Area |
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Very High Radiation Area |
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Contamination Area |
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Respirator Area |
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Other |
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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. |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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Radiation Work Permit |
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Radiation Worker Training |
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Respirator or Other Air Purifying Device |
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Anti-contamination Protective Clothes |
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Supplementary Dosimetry |
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Other |
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18. RADIATION
SOURCES: Would the project involve
the use or storage of any radiation sources? |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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X-Ray Machine / Generator |
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Sealed Radioactive Material |
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Accelerator |
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Unsealed Radioactive Material |
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Ultraviolet Light Sources |
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Other |
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19. OPERATIONAL
READINESS: Would the activity involve
one or more of the following? |
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Yes No Uncertain Not
Applicable |
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Yes |
No |
Unc |
Activity |
Explanation |
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Safety Review |
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Safety Class Items |
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Items under Configuration Control |
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Glove Boxes |
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Other |
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20. UNCONTROLLED
RELEASES: Would measures be in place
to manage possible uncontrolled emissions, discharge, or spills during any
phase of the project? |
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Yes No Uncertain Not Applicable |
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Explain: |
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21. EMERGENCY
RESPONSE: In the event of a release,
would the following be readily available in the work area? |
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Yes |
No |
Unc |
Activity |
Explanation |
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MSDS Information |
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Spill Control and Containment Materials |
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Phone numbers |
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Portable Fire Extinguishers |
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Warning Signs |
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Other |
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22. PERMITTING: Would the project/activity require
application for or modification of any of the following permits? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Excavation/Penetration |
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Burning Permit |
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Radiation Work Permit |
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Safety Work Procedure |
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Air Permit |
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Fugitive Emissions Permit |
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Existing VPDES Permit |
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Permit for Groundwater Dewatering |
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RCRA |
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Corps of Engineers |
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NESHAPs |
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Stormwater Management |
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Stormwater During Construction Activities |
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Other |
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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? |
|
||||
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Yes No Uncertain Not
Applicable |
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||||
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Yes |
No |
Unc |
Activity |
Explanation |
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Existing Wells or Boreholes |
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Existing Contaminated Groundwater |
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Excavations requiring Dewatering during Construction |
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Devices that could alter Groundwater Levels |
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New Monitoring Wells |
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New Soil Borings |
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24. PLANT/ANIMAL SPECIES: Has the project area been surveyed for
plants (or habitats of plants) or animals (or habitats) listed as follows? |
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Yes No Uncertain Not Applicable |
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Explain: |
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25. AQUATIC
SPECIES: Have waters in the project
area been surveyed for aquatic species listed as follows? |
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Yes No Uncertain Not
Applicable |
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26. HISTORICAL/ARCHEOLOGICAL: Has the proposed site been surveyed for
objects of historical/archeological significance? |
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Yes No Uncertain Not Applicable |
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Explain: |
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27. FLOODPLAIN: Would the project encroach upon or take
place within a floodplain? |
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Yes No Uncertain Not Applicable |
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Explain: |
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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. |
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Yes No Uncertain Not Applicable |
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Explain: |
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29. SITE
UTILIZATION: Would the proposed
project take place in any of the following? |
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Yes |
No |
Unc |
Activity |
Explanation |
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Developed Site(s) |
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Disturbed Site(s) |
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Undeveloped Site(s) |
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Pristine Area(s) |
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Other |
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30. EXCAVATION
ACTIVITY: If the project will require
any construction activity involving excavation or soil disturbance, estimate
the: |
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Area to be affected: |
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Volume of spoils: |
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Expected disposition of spoils: |
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What
control measures will be used to avoid soil erosion? How far away are the nearest surface water
bodies or drainage channels (including potential wetlands)? |
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31. ENVIRONMENTAL ASPECTS CHECKLIST |
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Aspects: The environmental aspects associated with
this project are: |
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Aspect Category (air, wastewater, haz waste, solid
waste, spill potential energy/nat. resources, other) |
Aspect |
Significant? (Y/N) |
SOP Number and Name |
Engineering Control (if needed) |
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Construction |
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Operations |
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Provide
any other project detail or explanation below: |
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DETERMINATION: |
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Yes |
No |
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Is an internal NEPA categorical exclusion (CXA), which cites existing
DOE-approved categorical exclusions (CXs), and if an AIC required? |
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Is a new CX or Project CX that needs DOE approval and requires? |
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Is DOE required to prepare an Environmental Assessment (EA). Associated AICs
are prepared by Jefferson Lab? |
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APPROVAL: |
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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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This has been completed by Facilities Management to
the best knowledge of the construction project scope and by the Jefferson Lab
Environmental Engineer for future building usage. If conditions or project scope change or
changes become evident, updated information will be provided to the Jefferson
Lab Environmental Engineer. |