environ checklist.docx
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- Attached to
- DOE Traineeship in Robotics
- Opportunity number
- DE-FOA-0001374
- Issued by
-
Department of Energy
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Environmental Checklist
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| robotics foa em - 8-4-15.pdf | ||
| robotics foa em - 8-4-15.pdf |
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450.02.IDF
4/11/2012 Rev. 0
APPLICANT
ENVIRONMENTAL CHECKLIST
| DIRECTIONS: |
| The following information must be provided to and approved by the Department of Energy (DOE) before a contractual document can be awarded. Complete this form and submit with project proposal. Complete and correct information expedites the review process. |
SECTION A.
| Project Title: |
| Applicant Organization: |
| Applicant Organization Contact (usually the PI): |
| Telephone Number and Email Address: |
SECTION B.
SOURCES OF POTENTIAL IMPACTS – Would the proposal involve or generate any of the following?
| YES |
| NO |
| YES |
| NO |
| 1. Radioactive Material Use |
| |_| |
| |_| |
| 10. Air Emissions |
| |_| |
| |_| |
| 2. Radioactive Waste Generation |
| |_| |
| |_| |
| 11. Asbestos Emissions or Waste |
| |_| |
| |_| |
| 3. Mixed Waste Generation |
| |_| |
| |_| |
| 12. Soil Disturbance |
| |_| |
| |_| |
| 4. Chemical Use/Storage |
| |_| |
| |_| |
| 13. Contaminated Soil |
| |_| |
| |_| |
| 5. Chemical Waste Disposal |
| |_| |
| |_| |
| 14. Water/Well Use |
| |_| |
| |_| |
| 6. Hazardous Waste Generation |
| |_| |
| |_| |
| 15. Discharge of Wastewater |
| |_| |
| |_| |
| 7. Industrial Waste Generation |
| |_| |
| |_| |
| 16. Work Within a Floodplain |
| |_| |
| |_| |
| 8. PCBs |
| |_| |
| |_| |
| 17. Cultural/Historical Resources |
| |_| |
| |_| |
| 9. Biological Hazards |
| |_| |
| |_| |
| 18. Interaction with Wildlife/Habitat |
| |_| |
| |_| |
SECTION C.
EXPLANATION OF POTENTIAL IMPACTS – For each impact marked “YES” in Section B, please provide a brief explanation. Indicate quantities involved and the office or procedure in place to handle use or disposal.
SECTION D.
CATEGORY EVALUATION CRITERIA, WOULD THE ACTION:
| YES |
| NO |
| 1. Is the activity covered by an existing NRC license? If yes, provide license #. |
| |_| |
| |_| |
| 2. Is the activity included in an Environmental Impact Statement or Environmental Assessment? |
| |_| |
| |_| |
| 3. Create hazardous, radioactive, PCB, or mixed waste for which no disposal is available? |
| |_| |
| |_| |
| 4. Require or modify federal, state, or local permits, approvals, etc.? |
| |_| |
| |_| |
| 5. Require siting, construction, or modification of a RCRA or TSCA regulated facility? |
| |_| |
| |_| |
| 6. Require cultural, historical, or biological clearances? |
| |_| |
| |_| |
SECTION E.
CERTIFICATION – To the best of the applicant' s knowledge at the time of signing, the responses given above are complete and accurate, and should new issues or concerns arise or changes occur anytime after award and during the course of performance, the applicant will alert DOE immediately.
| _______________________________________________ | _______________________ |
| APPLICANT SIGNATURE & TITLE | DATE |
FOR DOE USE ONLY
NEPA Doc Number:
Solicitation #:
NEPA CX Applied:
Contract Specialist:
Approved:
Signature/Date:
Project Manager:
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