A. UPDATE INFORMATION: Bio Cultural Special Waste
Submittal Date: (mm/dd/yyyy) Sequence No:

B. REASON FOR SUBMITTAL: (Check all that apply)
In-Stream Work Stream Name:
DETAIL the above in the Additional Information field.

C. PROPOSED WORK: (for this update only)
Proposed Work: Highway Bridge Bike Trail Other

D. TREE REMOVAL?: Number?: or Acres
Existing Bridge(s) Structure Number: - , - , -
Historic District Involved? Historic Buildings Involved?
Section 4(f) Lands Involved? Section 6(f) Lands Involved?

E.  FUNDING: Federal State TBP MFT Local Non-MFT
404 Permit Required          Anticipated Processing:

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


(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



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 


  * 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):
If any historical reference indicates the possible presence of a property or condition that may negatively affect the project site, then a PESA is required.

  If all responses for database search and site reconnaissance are "No", then the District Special Waste Coordinator may sign-off the project.
The Level 2 District Sign-off is valid for a maximum six months.  If any response for database search and  site reconnaissance is "Yes", or
if a database search or site reconnaissance is not performed or is inconclusive, then a PESA is required.

Conducted By:  
Telephone #: ( ) - Ext.
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.