2. Attachment B - Financial Assistance Environmental Checklist.docx

Attachment B

U.S. DEPARTMENT OF ENERGY

NATIONAL NUCLEAR SECURITY ADMINISTRATION (NNSA) HEADQUARTERS

FINANCIAL ASSISTANCE ENVIRONMENTAL CHECKLIST

Background for the Checklist: In compliance with the National Environmental Policy Act (NEPA), Department of Energy-funded activities are reviewed to determine if they will have any environmental impacts and, if so, what mitigating actions might be implemented. The attached form provides the information necessary for that NEPA review.

Checklist Instructions: Parts I, II, and III of the form are completed by the grant applicant. Part IV solicits information that the grant applicant may not be aware of so that Part, and any items of section 8 that are unclear, should be completed by the grant applicant in coordination with the environment, health, and safety coordinator/officer at each non-federal institution* at which the proposed project will be undertaken. Personnel at that office are asked to complete and sign Part V before returning the form to the applicant.

* Please note, Department of Energy National Laboratories are federal institutions.

U.S. DEPARTMENT OF ENERGY

NNSA HEADQUARTERS

FINANCIAL ASSISTANCE ENVIRONMENTAL CHECKLIST

Part I: Recipient Information Project Title:

Principal Investigator: Date:

Organization Name:

Solicitation Number: Award Number: (To be Completed by NNSA)

Part II: Project Description

1. Please describe the intended use of Department of Energy funding in your proposed project. Describe the project as specifically as possible, e.g., does it involve conducting a feasibility study, developing a design, data analysis, or education or outreach activities? Does it involve use of established research facilities, construction, capital purchases and/or equipment installation or modification? At what location(s) will the project be conducted? What is the desired outcome of the project?

2. Indicate below if the funding you are requesting will be applied to the entire project or only to support a phase of the project. |_| Entire Project |_| Project Phase Explain:

If you selected any option in item 4(A) or 4(B), please continue. If you did not select an option in item 4(A) or 4(B), please proceed to Part III, Certification.

6. Will the work to be performed take place entirely in existing buildings? |_| Yes |_| No

8. Potential Environmental Effects:

Insert an explanation for each “Yes” response in the table at the end of item 49.

36.

37.

Biosafety Level 3-4 Laboratory Greenhouse Gases (carbon dioxide, methane, nitrous oxide, hydrofluorocarbons, perfluorocarbons, or sulfur hexafluoride) A A If yes, please indicate in the table the amounts of each to be released to the atmosphere.

B If yes, please indicate in the table the approximate quantities and plans or arrangements for disposal.

Part III: Certification (to be completed by the grant applicant) I hereby certify that the information I have provided is current, accurate, and complete as of the date noted with my signature.

Email:

Part IV: Project Implications Will the proposed action involve the following? (To be completed by the applicant in coordination with the environment, health, and safety coordinator/officer at each non-federal institution at which the proposed project will be undertaken. Please insert an explanation in the table below for each “Yes” response.)

Number Explanation Contacts

Part V: Environmental Impacts Review (Part V is to be completed by each non-federal institution hosting the project.)

Part II of this form describes a project planned to take place at your institution. Based on that information and the information provided in Part IV, please respond to the following questions.

1. Is a National Environmental Policy Act or similar state-level review required for this project?

|_| Yes, please explain:

|_| No, please explain:

2. Does your institution have environmental permits (e.g., Resource Conservation and Recovery Act, Clean Air Act) or licenses (e.g., radioactive materials) to host this project?

|_| Yes, please explain:

|_| No, please explain:

If an existing radioactive materials license applies to the proposed project, please supply the number(s):

3. Will your institution be required to receive or modify environmental permits (e.g., Resource Conservation and Recovery Act, Clean Air Act) or licenses (e.g., radioactive materials) to host this project?

|_| Yes, please explain:

|_| No, please explain:

Additional comments:

I hereby certify that the information I have provided is current, accurate, and complete as of the date noted with my signature.