Form CD-593 U.S. DOC National Environmental Policy Act Environmental

_{OMB Control No. 0690-0028 Expiration Date: XX/XX/XXXX}

CD-593

(11-09)

U.S. Department of Commerce

National Environmental Policy Act (NEPA)

Environmental Questionnaire and Checklist

_{Proposed Project Name:}

_{Proposing Institution or Entity:}

Project Description:

_{(Briefly describe or attach synopsis of proposal):}

_{Amount of Project ($):}

Contact information for person completing the checklist:

_Name:

_{Phone Number:}

_{Organization:}

The Department of Commerce’s (DOC) Administrative Order implementing the National Environmental Policy Act (NEPA) of 1969, (as amended), requires environmental data or documentation to assist DOC in carrying out its responsibilities under NEPA. Therefore, it is necessary for the applicant to provide DOC with sufficient information concerning their proposed activity. Based on an environmental evaluation conducted at the project proposal phase, DOC will determine the appropriate level of environmental review. DOC will determine whether an environmental assessment or an environmental impact statement is necessary for the proposed activity or whether the activity can be

_{categorically excluded from additional NEPA review.}

DOC Environmental Questionnaire & Checklist Page 1 of 15

_{Instructions:}

The checklist is divided into two sections. Section 1 is for those projects that have historically shown no adverse impacts to the human or natural environment. These projects consist solely of administrative actions, personnel activities, or minor procurement activities. The following specific types of grant activities should use Section 1: those involving the purchase of computers or software going into existing facilities; issuance of fellowships; training or meeting facilitation in existing structures; printing of informational materials or brochures; the hiring of Census takers; and minor interior renovations are suggested to use this section. If the project falls into the one of the categories listed in Section 1, then you do not need to complete Section 2.

Section 2 is for those projects requiring ground disturbance of any kind, including building of facilities, installations, or structures; and any project with the potential to significantly impact the human or natural environment.

For Section 2, complete the following checklists based upon your knowledge of the proposed project site and immediate vicinity. If you are unable to determine the potential effect on a described resource, efforts should be undertaken to acquire available information on the resource or the effect of the project on the resource. If the proposal is determined to have an effect (checked “yes”) or the preparer is unable to determine if the proposal will have an effect (checked “unknown”), the project might be subject to further environmental review, notwithstanding other determinations under state environmental review laws and regulations. Failure to respond to the questionnaire because the impact is “unknown” can cause the processing of the application to be delayed until the applicant obtains the information and identifies the impacts, if any.

If the proposal is determined to have no environmental effect (checked “no”), the project may qualify for a categorical exclusion (CE) from further environmental review. DOC is ultimately responsible for determining if the proposal qualifies for a CE. If all elements

of the proposed project do not conform to the identified CE’s (published in the Federal Register on July 10, 2009), an Environmental Assessment (EA) or an Environmental Impact Statement (EIS) may be required prior to funding and/or initiation of the project. Prior environmental reviews may satisfy EA/EIS requirements. Enclose with this form copies of environmental review reports, including decision documents and evidence of public involvement.

_{Submit this completed form to:}

NOTES:

 Additional sheets may be used to explain responses to specific questions.

 DOC may require additional information.

SECTION 1

To be completed for those projects historically shown to not create significant environmental impacts to the human or natural environment. Note: If any answer is “No” or “Unknown”, please explain (additional documentation or review may be required to support a “No” or “Unknown” response).

Question	Yes	No	Unknown
1. Is the proposed action solely a procurement action for materials intended to be installed, stored or operated in an existing building or structure?
2. If the proposed action involves procurement of electronic equipment, will the equipment be disposed of in an environmentally sound manner at the end of its’ useful life?
3. Does the proposed action consist solely of personnel actions intended for Census activities?
4. Does the proposed action involve only minor interior renovations to a structure, facility, or installation?
5. Is the proposed action solely for the production and/or distribution of informational materials, brochures, or newsletters?
6. Does the proposed action encompass only literature surveys, inventories, data analysis, or audits?
7. Does the proposed action only involve the granting of fellowships?
8. Does the proposed action consist solely of training, teaching, or meeting facilitation at an existing facility or structure?

SECTION 2

To be completed for those projects involving ground disturbance or potential to significantly impact the human or natural environment. Please answer the

_{following questions:}

_{1. Are the personnel preparing this form familiar with the site?}

_{2. List the names of those individuals who conducted the site visit(s):}

_{3. List the date(s) of the site visit(s):}

_{4. Has consultation with all affected agencies or tribes been completed?}

5. Provide a description of all the coordination and consultation with other agencies and affected Indian tribes that has been completed where information from that coordination/coordination was used in the planning of the project or in evaluating possible environmental impacts (or attach equivalent information). If none, so state:

Description of agency/tribal contact	Date	Description of attendees/ recipients	Location

6. Provide a description of all the public involvement activities that have been completed where information from that involvement was used in the planning of the project or in evaluating possible environmental impacts (or attach equivalent _{information). If none, so state:}

Description of Activity	Date	Description of attendees/ recipients	Location

.

7. Please answer all of the questions in the following checklist. If you need additional space to respond, please attach an additional sheet of paper to this document

Question	Yes	No	Unknown
A. Is the proposed action part of a larger project?
If yes, please describe.
B. Do you anticipate requesting additional federal funding, permits or other federal actions for subsequent phases of the proposed project for which this document is submitted?
If yes, please describe.

Question	Yes	No	Unknown
C. Does this proposed action have the potential to be controversial because of substantial disagreement over possible size, nature or effect on environmental, cultural, or historical resources?
If yes, please explain.
D. Does this proposed action have the potential for significant impact as indicated by a federal, state, or local agency or Indian tribe?
E. Has any environmental review (e.g., NEPA documentation or state or tribal equivalent, permit, historic preservation consultation) been prepared for this proposed action?
If yes, please attach a copy of the document to this checklist.

Question	Yes	No	Unknown
F. If the proposed action includes an acquisition of real property (including a lease), has an Environmental Due Diligence Audit (e.g., ASTM E1527-13) been completed?
If yes, please attach a copy of the document to this checklist.
G. Would the proposed activity occur within a unique geographic area of notable recreational, ecological, scientific, cultural, scenic, or aesthetic importance (e.g., coral reefs; marine protected areas; national marine sanctuaries; essential fish habitat; habitat area of particular concern; park or refuge lands; wild or scenic  rivers; wetlands; prime or unique farmland; sites listed on the National Register of Natural Landmarks; sites that are ecologically significant or critical areas including areas that are normally inundated by water or areas within the 100-year flood plain)?
H. Is the proposed action directly related to other actions with individually insignificant, but cumulatively significant, environmental effects?
I. Will the proposed action have the potential to impact species listed or proposed to be listed on the List of Endangered or Threatened Species, or have adverse effects on designated Critical Habitat for these species?

Question	Yes	No	Unknown
J. Is there an intent to have the proposed action establish a precedent for future action or represent a decision in principle about future actions with potentially significant environmental effects?
K. Is the proposed action likely to:
i. Affect the water supplies of humans, animals, or plants?
ii. Affect the water table?
iii. Involve construction or use of a facility on or near an active geological fault?
L. Does the proposed action contribute to the introduction, continued existence, or spread of non-native invasive species or actions that may promote the introduction, growth or expansion of the range of non-native invasive species (EO 13112)?
M. Does the project involve the generation of ionizing or non-ionizing radiation or use of any radiation?

Question	Yes	No	Unknown
N. Does the proposed action involve construction on or near an active, inactive or abandoned toxic, hazardous or radioactive materials generation, transportation, treatment, storage, or disposal site?
If yes, will this require new or amended permits or approvals?
O. Will the proposed action involve generation, transportation, treatment, storage, or disposal of large amounts of solid waste in excess of local waste disposal facility capacity?
P. Will the proposed action involve storage or release of water contaminants (thermal, sediments, oxygen-depleting chemicals, pesticides, fertilizers, substances hazardous to human health, etc.) in amounts greater than allowed in currently existing permits?
Q. Will the proposed action involve use of a site that contains underground storage tanks (USTs)?
R. Will the proposed action involve use or release of ozone-depleting chemicals?

Question	Yes	No	Unknown
S. Will the proposed action violate local noise ordinances (e.g., levels, durations, or time limits)?
T. Does the proposed action involve the use of sonars or other underwater sound propagation devices?
U. Will the proposed action have disproportionate and adverse effects on the health or environmental risk of different population segments, such as children, the elderly, those with handicapping conditions, low income populations, or minorities (EO 12898)?
V. Will the proposed action have an ongoing pattern of pollutant discharge; traffic generation, patterns, or volumes; economic change, or land-use change in its locality that could collectively affect human health or the condition of the environment?
W. Will the proposed action have the potential to affect historic, archeological, or cultural sites, including Native American burial or ceremonial grounds, or properties listed or eligible for listing on the National Register of Historic Places?

Question	Yes	No	Unknown
X. Will the proposed action restrict access to and ceremonial use of Indian sacred sites by Indian practitioners or adversely affect the physical integrity of such religious sacred sites (EO 13007)?
Y. Will the proposed action involve a known archeological site, or land identified by archeologists as having high potential to contain archeological resources?
Z. Will the proposed action take place on property under the auspices of the National Capital Planning Commission?
AA. Will the proposed action involve emission of light or lasers exceeding established standards for persons or animals or affecting surrounding land and airspace uses (such as airports & astronomical observatories)?
BB. Will the proposed action potentially violate a federal, state, local, or tribal law, regulation, policy, or requirement imposed for the protection of the environment?

Question	Yes	No	Unknown
CC. Will the proposed action have the potential to impact migratory birds or their habitats?
DD. Will the proposed action require, in any part, review or permitting by any other federal, state, regional, local, environmental, or regulatory agency?
If yes, please list name of agency and type or review or permit needed.
EE. Will the proposed action affect a State's Coastal Zone Management Plan?
FF. Will the proposed action violate Occupational Health and Safety Administration (OSHA) standards?

Question	Yes	No	Unknown
GG. Is there the potential for the proposed action to have any other impacts on human health or the environment that have not been otherwise addressed in this questionnaire? If yes, please provide a description of such impacts and their significance.
If yes, please provide a description of such impacts and their significance.

8. Please describe any other aspects of the proposed action that could potentially affect the human or natural environment. Use a separate sheet if necessary.

_{Certification}

Project Name:
Proposing Institution:
Organizational Entity:
Signing Official:

Date: ______________

Public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other suggestions for reducing this burden to Steve Kokkinakis, NOAA Office of Program Planning and Integration: [email protected].

Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act (PRA), unless that collection displays a currently valid Office of Management and Budget (OMB) control number.