Illinois Department of Transportation, Ann L. Schneider, Secretary
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ENVIRONMENTAL SURVEY REQUEST ADDENDUM
 
A. PROJECT INFORMATION: Bio Cultural Special Waste
Submittal Date: (mm/dd/yyyy)Sequence No: PPS Project No.:
Contract #: Counties:
Route: Marked:
Street: Section:
Municipality(ies): Project Length: Miles
From To (At):
Quadrangle: Township-Range-Section:
Survey Target Date: (mm/dd/yyyy) Anticipated Design Approval: (mm/dd/yyyy)
(Six Months Minimum Required) 

B. REASON FOR SUBMITTAL: (Check all that apply)
Acquisition of additional ROW or easement Addendum acresTotalProject: acres
In-Stream Work Stream Name:
Other:
DETAIL the above in the Additional Information field.

The Additional Information field on this form should be used to expand on the Project Description.
C. ADDENDUM DESCRIPTION:

D. Existing Bridge(s) Structure Number: - , - , -
TREE REMOVAL?: Number?: or Acres

E.  LOCAL CONTACT PERSON: Telephone #: ( ) - ext.
Title: E-Mail:

F. ADDITIONAL INFORMATION: Memo By:

 
Page 2 - SPECIAL WASTE SCREEN
(Note: This screening is required only for ESRs requesting Special Waste survey. For all other survey types, proceed to end to submit form.
For questions about this form, please contact the District Special Waste Coordinator.)
Special Waste Submittal Date: mm/dd/yyyy
 
Step 1: Level 1 Screening Criteria
1.  Acquisition of additional right-of-way or easements (temporary or permanent)
2.  Railroad ROW (other than single rail rural ROW with no maintenance facilities)
3.  Excavation or subsurface utility relocation

  If all responses are "No", sign below and place in the appropriate report. The District Special Waste Coordinator may sign-off the project.  The Level 1
District Sign-off is valid for a maximum of six months. However, any projects  answering "Yes" or "Don't Know" to #2 above are not eligible for District
sign-off and must go through the PESA process.  If any response is  "Yes" or "Don't Know", continue to Step 2: Level 2 Screening Criteria.

Step 2: Level 2 Screening Criteria
If for any reason, the presence of any environmental condition cannot be determined from the site reconnaissance or from database searches,
please check this box, add an explanation below, and submit for PESA.
1. Does the project involve any of the following environmental conditions within the corresponding minimum search distance?

Environmental Condition

Minimum Search Distance

Database Search

Site Reconnaissance

Industrial and/or commercial property 

0.25 miles

 

Other Environmental Conditions*

Property & adjoining property

 

(Please detail below.) *

State UST

Property & adjoining property

 

State LUST 

0.5 miles

 

State Voluntary Cleanup, Brownfield, or landfills

0.5 miles

 

Federal NPL; NPL delisted, CERCLIS; CERCLIS NFRAP

1.0 miles; 0.5 miles; 0.5 miles;

 
 

0.5 miles, respectively

   

Federal RCRA CORRACTS facilities; RCRA non-CORRACTS TSD facilities

1.0 miles; 0.5 miles, respectively

 

Federal RCRA generators list 

Property & adjoining property

 

Federal RCRA Brownfield sites

0.5 miles

 

Federal ERNS System 

Property

 
  * Other Environmental Conditions are identified through site reconnaissance and include situations that may negatively affect the property including the
presence of, for example, illegal dumping, unknown containers, waste associated with "crack" or methamphetamine houses (i.e., discarded hazardous
material on the outside of a property), battery  piles, paint spills, abandoned transformers, surface staining, vegetative damage, etc.
* Describe Findings/Other
Environmental Conditions:

2. Were photographs taken of the site and/or surrounding area?

In an effort to identify any property or condition that may negatively affect the project site or potential historical, industrial and/or
commercial use, the following sources of information can be helpful while screening the project.
3. Place a check next to each reference that is reviewed.    (Optional)
  Google - type aerial maps Extranet data Historic Aerial Photos Survey Books Other Files & Photos
  City Directories County Assessor Sanborn Fire Insurance Maps Plat Books  
  Other source (describe):
After this Level 2 District Sign-Off has been completed, please email a screen shot of the form to the Central Office, BDE, Environment Section,
Geologic & Waste Assessment Unit for processing.

 
 
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