EHP Environmental Screening Form

Grant Programs Directorate

OMB No.: 1660-      

Expiration:

FEMA Form: 024-0-1

Burden Disclosure Notice

Public reporting burden for this form is estimated to average 14 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond to this collection of information unless it displays a valid OMB control number.  Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0072) NOTE: Do not send your completed form to this address.

ENVIRONMENTAL and HISTORIC PRESERVATION SCREENING FORM

This memo should be attached to all project information sent to the Grant Programs Directorate (GPD) for an environmental and historic preservation (EHP) regulatory compliance review. Complete sections A – D of this memo, as applicable. When questions are not applicable to the project, leave the field blank. This memo is intended to be completed electronically. Refer to Appendix A (page 10) for guidance on how to make an aerial map (if required for your project), and refer to Appendix B (page 11) for a list of online resources to help you provide visual documentation. Contact GPD-EHP for a version of this memo that is suitable for printing and completing by hand. To check (X) a box, left double-click using your mouse and a Check Box Field Form Box will appear. On the Check Box Field Form Box, select the default value as Checked and press OK. To write in a text field (     ), select the text field with your mouse and begin typing.

Your completed screening form with necessary attachments must be submitted to the Centralized Scheduling and Information Desk (CSID) at [email protected]  with the following information in the subject line of the e-mail: EHP Submission: Project Name, Subgrantee Name; Grant Award Number (i.e., EHP Submission: Camera Installation, Anytown Courthouse, 2010-AB-C1-2345).

A. PROJECT INFORMATION

Grant Program Name:       DHS Grant Award Number:       

Project Name:       Grant Fiscal Year: ___________ (Provide if no award number is available)

Project Type (Check all that apply): Physical security enhancements (i.e., installation of fencing, cameras, TWIC readers, bollards, motion detection systems, x-ray machines, lighting, etc.)

New installation/construction/renovation (i.e., emergency operations centers, docks, piers, security guard buildings, etc.)

Renovations/upgrades/modifications to structures 50 years old or older

Communication towers, related equipment, and equipment shelters

Other ground disturbing activities (i.e., trenching, excavation, etc.)

Training and exercises (specify whether classroom-based or field-based; field-based only require further information below)      

Purchase of equipment (specify type, and whether mobile/ portable, or installation will be required)      

Other (specify)      

Grantee Name (SAA):       Sub grantee Name: __________________

State:       County:       City:       Agency:      

Dollar value of grant (optional):      

B. PROJECT DESCRIPTION/LOCATION

The following information will be required in order to complete a review for each project type. If multiple “project types” describe the same project, [i.e., physical security enhancements AND renovations of structures 50 years old or older AND other ground disturbing activities], it is not necessary to repeat information; please make a note to refer back to the previous entry.

Enter Project Description:      

The project description should contain a brief summary of what specific action is proposed, where it is proposed, and how it will be implemented.

Project Type: Physical security enhancements (i.e., installation of fencing, cameras, TWIC readers, bollards, motion detection systems, x-ray machines, lighting, etc.)

Project Location (physical project address or latitude/longitude of project location):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

Color site photos attached (Required)

Ground-level site photos (showing where installations are proposed): Yes No

Aerial photograph with project limits outlined and with the location of any proposed installations identified (refer to Appendix A for guidance): Yes No

Will ground disturbance be required?

Yes (provide total extent (depth, length, and width)       No

Has the ground been previously disturbed? Yes No

FEMA Flood Insurance Rate Map (FIRM), with project limits outlined Yes No

If yes, please describe the current disturbed condition of the area (i.e., parking lot, commercial development, etc.):      

If no, include other visual documentation (see Appendix B for a list of online mapping resources):

Technical drawings/site plans (if available) Yes No

U.S. Fish and Wildlife Service, National Wetlands Inventory (NWI) Map, with project limits outlined Yes No

U.S. Department of Agriculture (USDA) Soil Survey Map, with project limits outlined

Yes No

Will any equipment or structures need to be installed? Yes No

If yes, please explain how and where this installation is proposed to be done (include site-specific photographs, and attach additional pages, if needed):      

Will the equipment use the existing infrastructure for electrical distribution systems?

Yes No

Are there any known structures or buildings that are 50 years old or older in the project area or immediate vicinity?  (If yes, please provide the location of the structure(s), ground-level color photos of these structures, and identify their location(s) on the aerial map; see Appendix B for the web address of the National Register of Historic Places) Yes No

Is there any previously completed environmental documentation for this project (i.e., environmental assessment, wetland delineation, archaeological study)? Yes (please attach documentation) No

Is there any previously completed agency coordination for this project (i.e., correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office, Tribal Historic Preservation Office)?

Yes (please attach documentation) No

Project Type: New installation/construction/renovation (i.e., emergency operations centers, docks, piers, security guardhouse, etc.)

Project Location (physical project address or latitude/longitude of project location):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

Describe the setting of the area where the new installation/construction/renovation is proposed (i.e., urban, suburban, or rural; forested or open field):      

Color site photos attached? (Required)

Ground-level site photos (showing where installations are proposed): Yes No

Aerial photograph with project limits outlined and with the location of any proposed installations identified (refer to Appendix A for guidance): Yes No

Will ground disturbance be required? Yes No

If yes, please give total extent (depth, length, and width):      

Has the ground been previously disturbed? Yes No

FEMA Flood Insurance Rate Map (FIRM), with project limits outlined Yes No

If yes, please describe the current disturbed condition of the area (i.e., parking lot, commercial development, etc.):      

If no, include other visual documentation (see Appendix B for a list of online mapping resources):

Technical drawings/site plans (if available) Yes No

U.S. Fish and Wildlife Service, National Wetlands Inventory (NWI) Map, with project limits outlined Yes No

U.S. Department of Agriculture (USDA) Soil Survey Map, with project limits outlined

Yes No

Will any equipment or structures need to be installed? Yes No

If yes, please explain how and where this is proposed to be done (include site-specific photographs, and attach additional pages, if needed):      

Are there any known structures or buildings that are 50 years old or older in the project area or immediate vicinity? (If yes, please provide the location of the structure(s), ground-level color photos of these structures, and identify their location(s) on the aerial map; see Appendix B for the web address of the National Register of Historic Places)? Yes No

Is there any previously completed environmental documentation for this project (i.e., environmental assessment, wetland delineation, archaeological study)? Yes (please attach documentation) No

Is there any previously completed agency coordination for this project (i.e., correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office, Tribal Historic Preservation Office)?

Yes (please attach documentation) No

Project Type: Renovations/upgrades/modifications to structures 50 years old or older

Is the building or structure listed in the National Register of Historic Places, or has it previously been determined eligible for listing in the National Register of Historic Places? (See Appendix B for the web address of the National Register of Historic Places) Yes No Unknown

Project Location (physical project address or latitude/longitude of project location):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

Color site photos attached? (Required)

Ground-level site photos (showing where installations are proposed): Yes No

Aerial photograph with project limits outlined and with the location of any proposed installations identified (refer to Appendix A for guidance): Yes No

Will ground disturbance be required?

Yes (provide total extent (depth, length, and width):       No

Has the ground been previously disturbed? Yes No

FEMA Flood Insurance Rate Map (FIRM), with project limits outlined Yes No

If yes, please describe the current disturbed condition of the area (i.e., parking lot, commercial development, etc.):      

If no, include other visual documentation (see Appendix B for a list of online mapping resources):

Technical drawings/site plans (if available) Yes No

U.S. Fish and Wildlife Service, National Wetlands Inventory (NWI) Map, with project limits outlined Yes No

U.S. Department of Agriculture (USDA) Soil Survey Map, with project limits outlined

Yes No

Will any equipment or structures need to be installed? Yes No

If yes, please explain how and where this is proposed to be done (include site-specific photographs, and attach additional pages, if needed):      

Are there any known structures or buildings that are 50 years old or older in the project area or immediate vicinity? (If yes, please provide the location of the structure(s), ground-level color photos of these structures, and identify their location(s) on the aerial map; see Appendix B for the web address of the National Register of Historic Places) Yes No

Is there any previously completed environmental documentation for this project (i.e., environmental assessment, wetland delineation, archaeological study)? Yes (please attach documentation)? No

Is there any previously completed agency coordination for this project (i.e., correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office, Tribal Historic Preservation Office)?

Yes (please attach documentation) No

Project Type: Communication towers, related equipment, and equipment shelters

Project Location (physical project address or latitude/longitude of project location):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

Color site photos attached? (Required)

Ground-level site photos (showing where installations are proposed): Yes No

Aerial photograph with project limits outlined and with the location of any proposed installations identified (refer to Appendix A for guidance): Yes No

For projects involving antenna (e) installations on existing towers, provide the height of the existing tower       and the height of the tower following the installation of the new antenna (e)      .

For new projects, state the total height (in feet) of the communication tower or structure, including any antennae to be mounted:      ­­­

If the proposed tower height is greater than 199 feet above ground level, state why this is needed to meet the requirements of the project:      

Will the tower be free-standing or require guy wires? Free standing Guy wires

If guy wires are required, state how many:      

State why a guyed tower is needed to meet the requirements of this project:      

Has an FCC registration been obtained for this tower? Yes No Registration #:      

Has the FCC E106 process been completed? Yes No

Has the FCC TCNS process been completed? Yes No If yes, attach all relevant environmental documentation submitted as part of the registration process, including use of the Tower Construction Notification System (TCNS), if applicable.

FRN#      (Required)

Will ground disturbance be required? Yes No

If yes, give total extent (depth, length, and width):      

Has the ground been previously disturbed? Yes No

FEMA Flood Insurance Rate Map (FIRM), with project limits outlined Yes No

If yes, describe the current disturbed condition of the area (i.e., parking lot, commercial development, etc.):      

If no, include other visual documentation (see Appendix B for a list of online mapping resources):

Technical drawings/site plans (if available) Yes No

U.S. Fish and Wildlife Service, National Wetlands Inventory (NWI) Map, with project limits outlined Yes No

U.S. Department of Agriculture (USDA) Soil Survey Map, with project limits outlined

Yes No

Will any equipment or structures need to be installed? Yes No

If yes, explain how and where this is proposed to be done (include site-specific photographs,

and attach additional pages, if needed):      

Are there any known structures or buildings that are 50 years old or older in the project area or immediate vicinity? (If yes, provide the location of the structure(s), ground-level color photos of these structures, and identify their location(s) on the aerial map; see Appendix B for the web address of the National Register of Historic Places) Yes No

Is there any previously completed environmental documentation for this project (i.e., environmental assessment, wetland delineation, archaeological study)? Yes (attach documentation) No

Is there any previously completed agency coordination for this project (i.e., correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office, Tribal Historic Preservation Office)?

Yes (attach documentation) No

Project Type: Other ground disturbing activities (i.e., trenching, excavation, fiber optics, etc.)

Project Location (physical project address or latitude/longitude of project location):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

Color site photographs and maps attached? (Required)

Ground-level site photos (showing where ground disturbance are proposed): Yes No

Aerial photograph with project limits outlined and with the location of any proposed ground disturbance identified (refer to Appendix A for guidance): Yes No

What type of ground disturbance is needed and why (i.e., utility trenching, etc.)?      

Provide the total extent of ground disturbance required (depth, length, and width):      

Has the ground been previously disturbed? Yes No

FEMA Flood Insurance Rate Map (FIRM), with project limits outlined Yes No

If yes, please describe the current disturbed condition of the area (i.e., parking lot, commercial development, etc.):      

If no, include other visual documentation (see Appendix B for a list of online mapping resources):

Technical drawings/site plans (if available) Yes No

U.S. Fish and Wildlife Service, National Wetlands Inventory (NWI) Map, with project limits outlined Yes No

U.S. Department of Agriculture (USDA) Soil Survey Map, with project limits outlined

Yes No

Will any equipment or structures need to be installed? Yes No

If yes, please explain how and where this is proposed to be done (include site-specific photographs, and attach additional pages, if needed):      

Are there any known structures or buildings that are 50 years old or older in the project area or immediate vicinity? (If yes, provide the location of the structure(s), ground-level color photos of these structures, and identify their location(s) on the aerial map; see Appendix B for the web address of the National Register of Historic Places) Yes No

Is there any previously completed environmental documentation for this project (i.e., environmental assessment, wetland delineation, archaeological study)? Yes (please attach documentation) No

Is there any previously completed agency coordination for this project (i.e., correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office, Tribal Historic Preservation Office)?

Yes (please attach documentation) No

Project Type: Training and Exercises (field-based only)

If the training is classroom-based, then no further information is required. If the training is field-based, then provide the following:

Will the field-based training take place at an existing facility having established procedures for that particular proposed exercise, and that conform with existing land use designations (refer to Information Bulletin #329 Clarification for further information)? Yes No

If yes, please provide the name and location of the facility:      

Does the training exercise differ in any way (frequency, amount of facilities/land used, materials or equipment used, number of participants, type of activities, etc.) from previously permitted training exercises and training practices? Yes No

If yes, explain any differences between the proposed activity and those that have been approved in the past, and the reason(s) for the change in scope.      

If yes, the field-based training is taking place at an existing facility (as described above), no further information is required. If the field-based training is not occurring at an existing facility, provide the following:

Project Location (physical project address or latitude/longitude of project location):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

Will ground disturbance be required to prepare the training site? Yes No

If yes, give total extent (depth, length, and width):      

If yes, provide visual documentation:

Color site photographs and maps attached? (Required)

Ground-level site photos (showing where installations are proposed):

Yes No

Aerial photograph with project limits outlined and with the location of any proposed installations identified (refer to Appendix A for guidance):

Yes No

Has the ground been previously disturbed? Yes No

FEMA Flood Insurance Rate Map (FIRM), with project limits outlined Yes No

If yes, describe the current disturbed condition of the area (i.e., parking lot, commercial development, etc.):      

If no, include other visual documentation (see Appendix B for a list of online mapping resources):

Technical drawings/site plans (if available) Yes No

U.S. Fish and Wildlife Service, National Wetlands Inventory (NWI) Map, with project limits outlined Yes No

U.S. Department of Agriculture (USDA) Soil Survey Map, with project limits outlined

Yes No

Will any equipment or structures need to be installed to facilitate training? Yes No

If yes, explain how and where this is proposed to be done (include site-specific photographs, and attach additional pages, if needed):      

Describe the scope of the proposed training (purpose, frequency, facilities/location needed, materials and equipment needed, number of participants, and type of activities required) (Attach additional pages, if needed):      

Is there any previously completed environmental documentation for this project (i.e., environmental assessment, wetland delineation, archaeological study)? Yes (please attach documentation) No

Is there any previously completed agency coordination for this project (i.e., correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office, Tribal Historic Preservation Office)?

Yes (please attach relevant documentation) No

Project Type: Purchase of equipment (specify what equipment, and the quantity; for generators, please state the capacity)      

Will any equipment need to be installed? Yes No

If yes, please explain how and where this is proposed to be done (include site-specific photographs, and attach additional pages, if needed):      

Year existing building(s) or structure(s) involved in the proposed project was built (Required): _________

C. CONSIDERATION OF RESOURCE IMPACTS

When completing this section, state a specific reason [i.e., “there will be no impacts to geology and soils because this project will not involve any ground disturbance”] and cite a source [i.e., local master plan, previous environmental assessment, correspondence with US Fish and Wildlife Service, correspondence with State Historic Preservation Office, FEMA Floodplain Insurance Rate Map (FIRM), etc.] to support a response of “no impact” or “potential to impact.” This section is not required for the purchase of mobile and portable equipment or classroom-based training, or field exercises to be conducted at an existing facility having established procedures for that particular proposed exercise.

Identify potential impacts to the following resources	No Impact	Potential to Impact	Reason/ Data Source/Agency
Noise
Air quality
Water resources, including surface water, groundwater, wetlands, coastal areas, and floodplains
Geology and soil resources, including prime and unique farmlands and hydric soils
Biological resources, including general vegetation, wildlife, wildlife habitat, migratory birds, and wetland habitat
Threatened and endangered species and critical habitat
Cultural resources, including architectural resources, archaeological resources, and Traditional Cultural Properties
Buildings or structures 50 years old or older
Socioeconomic resources, including economic development, demographics, and demand for housing and public services
Environmental justice (minority and low-income populations)
Aesthetics and visual resources
Human health and safety
Infrastructure, utilities, transportation and waste mgt.
Land use planning and zoning
Hazardous waste/ contamination
Community facilities and services

D. OTHER INFORMATION (answer the following questions/provide requested information.)

Are personnel preparing this form familiar with the site? Yes No

Did personnel visit site? Yes No

Is the project part of an approved plan such as a Master Plan or an Implementation Plan or any larger action with an accompanying National Environmental Policy Act (NEPA) document?

Yes (provide the plan name, and include a copy of the NEPA document) No

Is the project still consistent with the approved plan? Yes No

(If no, additional EHP compliance requirements may apply.)

Is the environmental document accurate and up-to-date? Yes No

(If no, additional EHP compliance requirements may apply.)

What was the decision of the NEPA document? (Check one, and please attach):

Finding of No Significant Impact (FONSI) OR

Record of Decision (ROD)

Agency Name       Date approved      

Appendix A. Aerial Photography Guidance

1. Obtain aerial photo; there are multiple online sources for aerial photos that are either free or request a nominal fee.

2. Copy the aerial image.

3. Open Microsoft Paint, Power Point, or other graphics-oriented software and paste the aerial image on the canvas.

4. Using drawing tools such as line drawing, shapes, and fill colors, label exactly where facility security enhancements will be installed i.e. fencing, lighting, cameras.

5. Cut and paste completed drawing into Word document and explain details of the facility security enhancements.

6. An example of a completed product is provided below.

Applicant Name: X Bus Company

Grant Program: FY 2008 Intercity Bus Security Grant Program

Grant Number: 2008-XX-XX-0000

Project Description: Facility Security Enhancements was awarded to X Bus Company in January 2009. Above are the enhancements that we wish to make to our facility. One camera will be installed. The building that the camera will be mounted on was built in 1975. The installation will include 6,412 linear feet of chain link security fencing. A total of 4 light posts will be installed. The light posts holes will cause 12” in diameter and 36” deep of ground disturbance.

If there are known historic resources (buildings, structures, districts, sites, etc.) within sight of the facility, indicate their location on the aerial photograph also. The National Register of Historic Places can be reviewed at: http://nrhp.focus.nps.gov/natreghome.do?searchtype=natreghome.

Appendix B. Online Mapping and Information Resources

National Register of Historic Places:

http://nrhp.focus.nps.gov/natreghome.do?searchtype=natreghome

FEMA’s Flood Insurance Rate Maps (FIRMs):

http://www.fema.gov/hazard/map/firm.shtm

National Wetlands Inventory:

http://www.fws.gov/wetlands/Data/Mapper.html

USDA Soil Survey Map:

http://websoilsurvey.nrcs.usda.gov/app/HomePage.htm

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