Application Part 2

Department of Defense
Office of Strategic Capital

FINAL WORKING DRAFT
OMB Control Number [•]
Expiration Date: [•], [•], [•]

Application Part 2
Contents
1.

Instructions............................................................................................................................................ 2
What is the purpose of Application Part 2? ...................................................................................... 2
What is a “Project or Transaction”? .................................................................................................. 2
Who can complete and submit the Application Part 2? .................................................................... 2
How detailed should responses be in Application Part 2? ................................................................ 2
What happens after the Applicant submits the Application Part 2?.................................................. 2
Confidential Treatment ..................................................................................................................... 3
What to submit with the Application Part 2:..................................................................................... 3
2. General Information .............................................................................................................................. 4
3. Applicant Summary .............................................................................................................................. 4
4. Transaction Summary ........................................................................................................................... 5
5. Additionality ......................................................................................................................................... 6
6. Financial Information............................................................................................................................ 6
7. Borrower Representations and Warranties............................................................................................ 7
8. Timeline ................................................................................................................................................ 7
9. Project/Transaction Assessments .......................................................................................................... 8
10.
Administrative Information............................................................................................................. 10
a) OSC Application Information ......................................................................................................... 10
b) Application Submission Expectations ............................................................................................ 10
c) Signatures........................................................................................................................................ 10
11.
Privacy Advisory ............................................................................................................................ 10
12.
Paperwork Reduction Act Statement .............................................................................................. 11
a)
b)
c)
d)
e)
f)
g)

Annex A: Environmental Screening Questionnaire

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1. Instructions
The following application is the second part of a two-part application (“Application Part 2”, and together
with Application Part 1 (as defined below), the “Application”). Please review the instructions in full for
information on eligibility, processing, and other guidance related to applying for financing from OSC.
Additionally, OSC has a Frequently Asked Questions section on its website, https://www.cto.mil/osc, that
provides additional elaboration on the Application Part 1, OSC, and related issues.
a) What is the purpose of Application Part 2?
The purpose of Application Part 2 is to further assess the eligibility of the proposed project or transaction
as established in the first part of the application (“Application Part 1”) and provide additional financial and
technical information to OSC to assess the suitability based on OSC’s strategic program priorities and
requirements. For the purposes of this Application, eligibility criteria is defined in Section 8140 of the
Further Consolidated Appropriations Act, 2024 (FCA; 118-47) and Section 504 of the Federal Credit
Reform Act of 1990 [(FCRA; 2 U.S.C. § 661c) (FCRA Section 504)], which limits federal participation in
loans and guarantees.
b) What is a “Project or Transaction”?
The phrase “Project or Transaction” as used throughout this Application Part 2 refers to the underlying
commercial project or transaction for which the Applicant (as defined below) seeks financing, whether it is
an actual project (such as a “greenfield” project to build a manufacturing plant) or a discrete equipment
purchase, or anything in between. Applicants may group similar transactions in this Application Part 2 (e.g.,
equipment purchases for multiple locations), but eligibility needs to be assessed for each transaction.
c) Who can complete and submit the Application Part 2?
Application Part 2 is to be completed by Applicants who have successfully passed OSC’s initial assessment
following submission of Application Part 1 and received a written invitation to submit Application Part 2.
The application form can be completed by the prospective borrower (the “Borrower” or the “Applicant”),
its related parties, or other affiliated third parties such as advisors, counsel, or financial institutions. If filed
by an affiliated third party, an official mandate of authority must be submitted along with the Application
Part 2. In all cases, the Application Part 1 must be signed by the Borrower or, if applicable, the Sponsor. In
a Project or Transaction as to which the borrower is a special purpose vehicle with no history, the
application must be signed by the majority or controlling sponsor of the project.
d) How detailed should responses be in Application Part 2?
Answers to this Application Part 2 should be in the form of attached documents (.PDF preferred) and
Applicants may provide additional elaboration in the text boxes provided. There is no limit to the amount
of detail Applicants may provide in any instance, but Applicants should maintain a focus on the question
itself and not unnecessarily elaborate beyond the scope of any discrete inquiry.
e) What happens after the Applicant submits the Application Part 2?
The Application Part 2 will obtain detailed information to further assess the project’s eligibility, suitability,
and viability. Approval of the application is in the sole discretion of OSC. In deciding whether to approve
the application, OSC may consider factors including but not limited to transaction specific risks, detailed
financial information and projections, and OSC’s strategic priorities. If necessary, and with advance notice,
OSC will engage Independent Financial and Technical Advisors to perform assessment and due diligence.
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The cost associated with engaging such advisors will be borne by the Applicant. At the conclusion of due
diligence, OSC communicates the final decision to the Applicant, and, if the Application is approved, the
parties will proceed to document the financing for the project or transaction.
f) Confidential Treatment
The Applicant should identify with clear markings any information or document that the Applicant
customarily treats as confidential and should indicate the time period for which it seeks such confidential
treatment. Information covered by a confidentiality claim will be disclosed by OSC only to the extent and
only by means of the procedures set forth under 32 C.F.R. Subchapter N.
g) What to submit with the Application Part 2:
The Application Part 2 submission must include:
1. A completed, signed version of Application Part 2;
2. All attachments requested and referenced in the Application Part 2; and
3. Signed mandate letter for representing the Borrower or Sponsor (applicable if Application Part 2
is filed by a third party)
How to submit the completed Application Part 2
When finished, the Application Part 2 form and attachments may be submitted by emailing OSC at
[[email protected]], with the subject line: “[NAME OF BORROWER/SPONSOR] –
[NAME OF PROJECT] – Application Part 2 Submitted”. Hard copy submissions will not be accepted. OSC
strongly suggests that the applicant submit the application in an encrypted format and separately provide
OSC with instructions on accessing the documents once received.

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APPLICATION PART 2 –
QUESTIONS AND REQUESTS FOR INFORMATION AND DOCUMENTS
Please type your responses to the following questions. The processing of Application Part 2 may be
delayed if the requested information is not provided.
Please note: If any items have material changes since submission of Application Part 1, provide a
separate attachment detailing those changes with this application.
2. General Information
Application Part 1 number (to be provided by OSC on invitation to proceed with Application Part 2):

Full legal name of the Borrower, to include entity form (e.g., C Corporation, LLC, LP):
This entity name should be the same as provided in Application Part 1. If the Borrower has been subject to
a name change, organizational change, or a merger resulting in a new name please set forth the new name
and enter the phrase “formerly known as” or “FKA” followed by the former name provided in Application
Part 1.

3. Applicant Summary
Description of key business activities, key products and services, the customer or off-taker base for these
key products and services, and, if different than the customer or off-taker base, the end user base.

Identify by names and location the key customers or off-takers, and, if different, key end-users, of the key
products and services identified in the preceding question.

If not included in an Information Memorandum submitted with the application, provide the names of, and
a brief biography for, the ultimate beneficial owners, managers (C-level executives or equivalent), and
board directors of the Borrower, as well as any other person or entity that exercises control over significant
decisions of the Borrower.

Provide a detailed organizational chart outlining the full ownership (or prospective ownership) structure of
the prospective borrower, including all direct and indirect subsidiaries (if any), and all direct and indirect
owners up to the ultimate beneficial owners. An ultimate beneficial owner is an individual(s), a government,
or a widely held, publicly-traded entity. In the event the ultimate beneficial owner is a widely held, publiclytraded entity, please also identify all persons or entities that own more than 5% of such entity. If the

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prospective borrower is a special purpose vehicle, please also provide an equivalent detailed organizational
chart for all sponsors of the project and indicate the voting percentages of each sponsor.

If the prospective Borrower will be a special purpose vehicle with no history, please provide a detailed
organizational chart or charts of the structure of the project, including all sponsor ownership and voting
percentages, and other major parties including major contractors, lenders, and governmental entities
involved.

4. Transaction Summary
Please provide:
a) an organizational chart or charts of the structure of the underlying commercial project or
transaction, including other major parties such as major contractors, lenders, and governmental
entities involved, and key project or transaction managers.
b) if not included in response to the preceding question a detailed chart or charts of the structure of
the proposed financing, including all capital flows, for the project or transaction.
c) responses to the environmental screening questions attached as Annex A to this Application Part
2.
d) a detailed chart or charts illustrating the flow of sales, the shipments of the products or the delivery
of services, and counterparty responsibilities, if relevant.

If not included in the chart or charts responsive to the preceding question, please summarize the details of
key customers or off-takers and, if different, the end users for the products or services to be offered in
connection with this Transaction.
Provide the details about the proposed capital structure for the Project or Transaction, to include ultimate
beneficial owner(s), any key intermediate entities, and details on proposed lenders or the projected
debt/equity ratio.

Provide details if there are existing lenders to the project or transaction, the existing debt structure, and
terms.

Provide details about proposed equity capital structure for the Borrower. Provide details about information
on major shareholders, number and series of shares outstanding, share price history or estimated private
valuation (i.e., a current 409A), and provide a description of any planned equity issuances.

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5. Additionality
Has the Borrower applied to other federal financing sources for the project (e.g., Small Business
Administration, CHIPS, U.S. International Development Finance Corporation, U.S. Export-Import Bank,
other grants or loans)? If so, (i) what is the primary point of contact at the referenced agency (name, title,
email phone), and (ii) what is the outcome of the engagement?

Are commercially viable sources of financing available for the Borrower’s project? If not, please describe.

Is the Borrower in competition with internationally-based suppliers and / or service providers? If yes,
identify the countries and describe the name of the competitor(s) and nature of competition(s).

Are there structural, regulatory, market, or other risk constraints that limit the Borrower’s proposed Project
or Transaction’s access to commercially viable sources of financing?

Is the Borrower being offered financing from foreign public or private capital providers? If so, please list
the entities and the countries.

Are you seeking OSC financing to diversify your existing source of capital?

6. Financial Information
a) Please submit the Borrower’s most recent audited Financial Statements (including Income
Statement, Balance Sheet, and Statement of Cash Flows) for at least the last three years, as
applicable. If these audited financials are not available, please explain.
b) If the Transaction receives a corporate guarantee from a parent or affiliate, please provide the last
three years of audited financial statements of the guarantor.
c) If the Transaction receives a personal guarantee from an owner, manager or other third-party, please
provide a personal financial statement (a Form 413 from the Small Business Administration would
be acceptable).

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d) Please provide information on any proposed assets or credit enhancements to be pledged as
collateral to support the financing, such as inventory, receivables, immovable assets, contracts,
marketable securities, cash accounts, shares, and letters of credit.
e) Provide a financial model that includes pro forma Financial Statements and Projections that
illustrate key business inputs and assumptions, profitability metrics (e.g. gross profit margin,
operating profit margin, EBITDA), risk and debt metrics (e.g. cash flow available for debt services,
debt service coverage ratio) for the Project or Transaction, as applicable. The pro forma model
should represent the business base case over the life of the proposed OSC loan tenor. The pro forma
Financial Statements should be in the format of a dynamic, integrated spreadsheet within Microsoft
Excel, allowing variable input and scenarios for key assumptions. To the extent possible, Financial
Statements should endeavor to adhere to Generally Accepted Accounting Principles (“GAAP”) or
comparable standards.
f) Include a sensitivity analysis for both upside and downside scenarios. The financial model should
include parameters such as interest rates, inflation, interest capitalization, interest only periods,
amortization schedules and any contingencies, as applicable.
g) Provide details into maintenance of the assets to be financed in connection with this Application,
covering their life cycle to maximize their value and effectiveness. Include detailed maintenance
plans, schedules for routine maintenance activities, procedures for unexpected repairs or issues,
and strategies for ensuring compliance with industry regulations.
h) Have there been any material changes (either positive or negative) in the financial condition,
business operation of the Applicant, or in the competitive environment in which the Applicant
operates since the dates of the Financial Statements submitted? Yes ___/ No ___. If “yes” please
briefly explain.

7. Borrower Representations and Warranties
If you answer “Yes” to any questions, please briefly explain.
a. Is the Borrower party to a lawsuit or a civil action, either filed or threatened?
b. Has the Borrower been involved in bankruptcy proceedings in the last 10 years?
c. Does the Borrower have delinquent federal, state, payroll, sales, or other tax liability?
d. Has the Borrower had property foreclosed upon or given title or deed in lieu?
e. Does the Borrower, to its knowledge, have any stockholders or contract partners that are subject to
sanctions from the United States Department of the Treasury, United States Department of State,
United States Department of Commerce?
8. Timeline
Please identify any revisions to the estimated timeline provided in Application Part 1, if applicable.

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Please provide an actual or, (if an actual projection is unavailable) an estimated timeline for the following,
which should conform with the information provided in the financial model:
a) Capital expenditure phases of the project.
b) A contract matrix with estimated material contracts with key counterparties in the project, including
any material equipment or services being purchased. The contract matrix should include:
(i) counterparty name, (ii) contract type (iii) contract timeline (estimate shipment, installation
and/or service provision start date), (iv) contract value, and (v) contract considerations. If there is
more than one contract for the same purchase or service, identify the date range for the contracts.
c) A permit matrix with estimated permitting and approval requirements from local, state or Federal
authorities (e.g. construction permits, U.S. Army Corps of Engineers nationwide permits,
California Environmental Quality Act). The permitting matrix should include: (i) permit name,
(ii) permit trigger, (iii) permit submission and review timeline, (iv) permit considerations and
(v) issuing agency.
d) Contract date for the equipment or service being purchased? If there is more than one purchase
contract, identify the date range for the contracts.
e) Estimated shipment, installation and/or service provision start date.
f) Estimated duration of project preparation, construction, installation, shipment, and service
provision.
g) Estimated project completion and commercial start date for the project.
h) Technical and economic useful life of the project facility, and/or the equipment or services being
financed.
i)

Milestone and/or progress payment schedule and amount for items being financed under
Transaction.

j)

Proposed Financing Timeline. Please provide the expected time frame for the following:
(i) Financial close (including all required funding for the project or transaction), (ii) Loan
availability date (i.e., date of first draw), (iii) Loan availability duration (i.e., drawdown period),
(iv) Loan grace period, and (v) Loan repayment period.

9. Project/Transaction Assessments
Where applicable, attach to the Application a copy of the most recent internal or external feasibility
assessments or documentation, including but not limited to the following:
•

Information Memorandum outlining the project’s strategy; objectives, assets available,
assumptions, and risks.

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•
•
•
•
•
•
•
•
•
•

Market study.
Financial due diligence.
Engineering assessment / Technical study.
Environmental study or impact assessment.
Social/labor study or impact assessment.
Commercial feasibility.
Insurance assessment.
Legal and regulatory assessment.
Credit rating reports.
Key transaction contracts (e.g., sales/purchase agreements, service agreements, operation &
maintenance contract, engineering procurement construction contract, feedstock report).

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10. Administrative Information
a) OSC Application Information
Is there other information about the proposed Project or Transaction or the proposed financing that OSC
should know? (Optional):

b) Application Submission Expectations
OSC will review Application Part 2 upon receipt. OSC will determine suitability of the applicant based on
the information submitted, aligning with the program’s objectives and meeting the eligibility criteria
pursuant to Section 8140 (as defined in Application Part 1).
c) Signatures
Application Part 2 should be signed below by an authorized representative of the Borrower or the Sponsor
and, if applicable, the Guarantor. In the case of a project finance transaction wherein the prospective
borrower has not been created, the Application Part 2 should be signed by the lead Sponsor.
By signing below, the signing party certifies, under penalties of perjury, that all information provided in
this Application Part 2 is true and correct to the best of the applicant’s knowledge and belief after conducting
reasonable diligence.
11. Privacy Advisory
a. Authority: The information requested by this application is authorized by the National Defense
Authorization Act for Fiscal Year 2024 (NDAA), Section 903 (Pub. L. 118-31).
b. Purpose: The information requested by this application will be used to determine whether the loan
transaction presents a reasonable assurance of repayment, meets the eligibility requirements set
forth in NDAA Section 903 and Section 8140 of the Further Consolidated Appropriations Act,
2024, and supports the mission of the Office of Strategic Capital to source and scale private
investment in critical supply chain technologies needed for national security. The information
collected will also be used for “know your customer” purposes to assure that transaction parties do
not have ownership, control, or influence from or by foreign parties adverse to the United States.
c. Uses: While the information requested by this application is primarily intended to be used
internally, in certain circumstances it may be necessary to disclose this information externally,
including to contractors, experts, consultants, and others performing or working on a contract,
service, or other assignment for the Federal Government, when necessary to accomplish an agency
function.
d. Disclosure: Voluntary. Provision of the information requested by this application is voluntary.
However, failure to provide the requested information may result in the Office of Strategic Capital
being unable to determine eligibility for capital assistance and rejection of a loan application. At
all times, the Office of Strategic Capital reserves the right to decline to process or to discontinue
processing any application.

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e. OMB Control Number: The Office of Strategic Capital may not require the information requested
by this application, and applicants are not required to provide the requested information, unless a
currently valid OMB control number is displayed on this application form.
12. Paperwork Reduction Act Statement
The Office of Strategic Counsel estimates that it will take the applicant approximately 40 hours to complete
this form. This includes the time it will take to read the instructions, gather the necessary facts, information,
and documents, and fill out the form. If you have comments or suggestions regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing the burden, send
correspondence to the Department of Defense, Washington Headquarters Service, at [email protected]. Applicants should be aware that, notwithstanding
any other provisions of law, no person shall be subject to any penalty for failing to comply with a collection
of information if it does not display a currently valid OMB control number.
[Remainder of Page Left Blank]

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BY SIGNING BELOW, applicant certifies, under penalties of perjury, that all information provided in
this Application Part 2 is true and correct to the best of the applicant’s knowledge and belief after conducting
reasonable diligence.
BORROWER
[•] 1

____________________________________
Name: [•] 2
Title: [•] 3
Address: [•] 4
Email: [•] 5

NTD: Add full legal name of entity.
NTD: Add full legal name of authorized signatory.
3
NTD: Enter title of signatory – title must correspond with appointment under corporate governance documentation.
4
NTD: Enter address for signatory.
5
NTD: Enter contact email for signatory.
1
2

(Signature Page to Application Part II – Borrower)

BY SIGNING BELOW, applicant certifies, under penalties of perjury, that all information provided in
this Application Part 2 is true and correct to the best of the applicant’s knowledge and belief after conducting
reasonable diligence.
SPONSOR
[•] 6

____________________________________
Name: [•] 7
Title: [•] 8
Address: [•] 9
Email: [•] 10

NTD: Add full legal name of entity.
NTD: Add full legal name of authorized signatory.
8
NTD: Enter title of signatory – title must correspond with appointment under corporate governance documentation.
9
NTD: Enter address for signatory.
10
NTD: Enter contact email for signatory; include contact information for legal counsel if desired.
6
7

(Signature Page to Application Part II – Sponsor)

BY SIGNING BELOW, applicant certifies, under penalties of perjury, that all information provided in
this Application Part 2 is true and correct to the best of the applicant’s knowledge and belief after conducting
reasonable diligence.
GUARANTOR
[•] 11

____________________________________
Name: [•] 12
Title: [•] 13
Address: [•] 14
Email: [•] 15

NTD: Add full legal name of entity.
NTD: Add full legal name of authorized signatory.
13
NTD: Enter title of signatory – title must correspond with appointment under corporate governance documentation.
14
NTD: Enter address for signatory.
15
NTD: Enter contact email for signatory; include contact information for legal counsel if desired.
11
12

(Signature Page to Application Part II – Guarantor)

Annex A – Application Part 2
OSC Environmental Screening Questionnaire
The following questionnaire is designed to help OSC determine whether or not your project or transaction
implicates the National Environmental Protection Act (“NEPA”). Please answer each question to the best
of your ability and OSC will use your responses to evaluate whether NEPA regulations will apply, if an
existing categorical exclusion is in place, or if other measures are necessary to complete your proposed
project or transaction.
“Project or Transaction”, as defined in Application Part 2, Section 1(b), refers to the project or transaction
for which the application seeks financing. The term “project” as used in the following environmental
screening questions must be interpreted more broadly and includes any transportation, reclamation,
installation, refurbishment, upgrade, construction, repair, and ongoing use, operation and maintenance of
real property, goods or equipment used in preparation for, installation of, and operation, maintenance and
repair of machinery or equipment.
1) Please state the address for the site of the project or place where any equipment will be installed,
replaced, or refurbished. (If the project or transaction being financed will take place at more than one
site or address, please complete this questionnaire for each site or address).

2) Has the applicant or anybody on the applicant’s behalf conducted an environmental review,
environmental assessment, or environmental impact study in connection with the project? Yes ___ No
___
If “yes” please provide a copy.
3) Will the project involve the installation or relocation and operation of machinery or equipment? Yes
___ No ___
If “yes”:
i)

Will the uses of the newly installed or relocated machinery and equipment be consistent
with the general missions of the receiving structure? Yes ___ No ___
If you replied “no” to sub-question (i) above, please skip ahead to question 10. If you
replied “yes”, proceed to sub-question (ii) below.

ii) Will the installation or relocation of the machinery or equipment involve any modifications
to an existing building? Yes ___ No ___
If you replied “no” to sub-question (ii) above, proceed to question 4 below. If you replied
“yes” to sub-question (ii) above, are such modifications:
(a) Necessary for the installation or relocation of the machinery and equipment? Yes ___
No ___
(b) Within or contiguous to a previously disturbed or developed area? Yes ___ No ___
If you replied “yes” to both sub-questions (a) and (b) please proceed to question 4 below.

If you replied “no” to either sub-questions (a) or (b), please skip ahead to question 10.
4) Will the project threaten a violation of applicable statutory, regulatory, or permit requirements for
environment, safety, and health, or similar requirements of an Executive Order? Yes ___ No ___
If “yes” please briefly explain:

5) Will the project require siting and construction or major expansion of waste storage, disposal, recovery,
or treatment facilities (including incinerators)? Yes ___ No ___
If “yes” please briefly explain:

6) Will the project disturb hazardous substances, pollutants, contaminants, or CERCLA-excluded
petroleum and natural gas products that preexist in the environment, such that there would be
uncontrolled or unpermitted releases? Yes ___ No ___
If “yes” please briefly explain:

7) Will the project have the potential to cause significant impacts on environmentally sensitive sources
that have been identified as needing protection through an Executive Order, statute, or a regulation
issued by Federal, state or local government or a federally recognized Indian Tribe? Yes ___ No ___
If “yes” please briefly explain and skip ahead to question 9.
If “no” please proceed to question 8 below.

8) Will the project have the potential to cause significant impacts on any of the types of areas or species
listed below in a - g? Yes ___ No ___
If “yes” please briefly explain:

a. Property (such as sites, buildings, structures, and objects) of historic, archeological, or
architectural significance designated by a Federal, state, or local government, federally
recognized Indian tribe, or Native Hawaiian organization, or property determined to be
eligible for listing on the National Register of Historic Places.
b. Federally listed threatened or endangered species or their habitat (including critical habitat)
or Federally-proposed or candidate species or their habitat (Endangered Species Act); statelisted or state-proposed endangered or threatened species or their habitat; Federallyprotected marine mammals and Essential Fish Habitat (Marine Mammal Protection Act;
Magnuson-Stevens Fishery Conservation and Management Act); and otherwise Federallyprotected species (such as the Bald and Golden Eagle Protection Act or the Migratory Bird
Treaty Act).
c. Floodplains and wetlands.

d. Areas having a special designation such as Federally- and state-designated wilderness
areas, national parks, national monuments, national natural landmarks, wild and scenic
rivers, state and Federal wildlife refuges, scenic areas (such as National Scenic and Historic
Trails or National Scenic Areas), and marine sanctuaries.
e. Prime or unique farmland, or other farmland of statewide or local importance, as defined
at 7 CFR 658.2(a), “Farmland Protection Policy Act: Definitions,” or its successor.
f.

Special sources of water (such as sole-source aquifers, wellhead protection areas, and other
water sources that are vital in a region). Or

g. Tundra, coral reefs, or rain forests.
9) Will the project involve genetically engineered organisms, synthetic biology, governmentally
designated noxious weeds, or invasive species? Yes ___ No ___
If “yes”, will the project be contained or confined in a manner designed and operated to prevent
unauthorized release into the environment and conducted in accordance with applicable requirements,
such as those of the Department of Agriculture, the Environmental Protection Agency, and the National
Institutes of Health? Yes ___ No ___
If you replied “no” to the preceding sub-question above, please briefly explain.

10) Will the project involve the movement, handling, use or distribution of materials, including hazardous
materials or wastes? Yes ___ No ___
If ‘yes”, will such movement, handling, or distribution:
i) Be routine? Yes ___ No ___
ii) Be done in accordance with applicable regulations such as the Resource Conservation and
Recovery Act (RCRA), Occupational Safety and Health Administration (OSHA), and
Hazardous Materials Transportation Act (HMTA)? Yes ___ No ___
If you replied “no” to either sub-question (i) or (ii) above, please briefly explain.

11) Will the project be conducted in an existing non-historic structure? Yes ___ No ___
If “no”, please briefly explain.

If “yes”:
i)

will the project result in a use of the structure that is not within the scope of and compatible
with the present functional use of the structure? Yes ___ No ___
ii) will the project cause more than a marginal increase in waste discharged to the environment?
Yes ___ No ___

iii) Will the project result in different waste discharges from current or previous activities in the
structure? Yes ___ No ___
iv) Will emissions remain within current permit levels, if any? Yes ___ No ___ N/A ___
If you answer “yes” to any of sub-questions (i) through (iv), please briefly explain.

12) Will the project involve any acquisition, installation, modification, or routine repair and replacement
and operation of any utility (e.g., water, sewer, and electrical) or communications systems, mobile
antennas, data processing cable or similar electronic equipment? Yes ___ No ___ N/A ___
If “yes”, will such acquisition, installation, modification, or routine repair use only existing rights-ofway, easements, distribution systems, facilities, or previously disturbed land? Yes ___ No ___
If you replied “no” to the preceding sub-question, please briefly explain.

13) Will the project involve research, testing or operations such as wind tunnels, high-energy lasers,
remote-sensing instruments, vacuum chambers, high-altitude simulator facilities or propellant testing
facilities? Yes ___ No ___
If “yes”, will the research, testing and operations:
i) be conducted solely at existing facilities, plants, or laboratories? Yes ___ No ___
ii) be done in compliance with all applicable safety, environmental, and natural conservation
laws? Yes ___ No ___
If you replied “no” to either sub-questions (i) or (ii) above, please briefly explain.

14) Will the project involve construction of an addition to an existing structure or new construction on a
previous undisturbed site? Yes ____ No ___
If “yes”:
i)

Will the area to be disturbed be greater than 5.0 cumulative acres of new surface disturbance?
Yes ___ No ___
ii) does the construction include construction of facilities for the transportation, distribution, use,
storage, treatment, or disposal of solid waste, medical waste, or hazardous waste? Yes ___ No
___
If you replied “yes” to either sub-questions (i) or (ii) above, please briefly explain.

15) Will the project involve the demolition of buildings, structures or other improvements and removal of
debris therefrom, or removal of a part thereof for disposal? Yes ___ No ___
If “yes”:
i) Will the demolition be only of non-historic buildings, structures, or other improvements? Yes
___ No ___

ii) Will the demolition and removal of debris for disposal be in accordance with applicable
regulations, including those applying to removal of asbestos, polychlorinated biphenyls
(PCBs), lead-based paint, and other special hazard items? Yes ___ No ___
If you replied “no” to either sub-question (i) or (ii) above, please briefly explain.

16) Will the project involve road or trail construction or repair? Yes ___ No ___
If “yes”, will the road or trail construction or repair be limited to existing rights of way or previously
disturbed areas? Yes ___ No ___
If you replied “no” to the preceding sub-question, please briefly explain.

17) Will the project involve the modification, product improvement, or configuration engineering design
change to materiel, structure, or item? Yes ___ No ___
If “yes”, will the changes to materiel, structure or item change the original impact of the materiel,
structure, or item on the environment? Yes ___ No ___
If you replied “yes” to the preceding sub-question, please briefly explain.

18) Will the project involve warrants or acquisitions of leases, licenses, easements, or permits for use of
real property or facilities? Yes ___ No ___
If “yes”, will there be any significant change in land or facility use? Yes ___ No ___
If you replied “no” to the preceding sub-question, please briefly explain.

19) Will the project involve acquisition of real property (including facilities)? Yes ___ No ___
If “yes”:
i) Will the land use remain substantially the same? Yes ___ No ___
ii) Will the acquired land total less than 40 acres? Yes ___ No ___
iii) Will the use be similar to current or ongoing activities on adjacent land? Yes ___ No ___
If you replied “no” to any of sub-questions (i) – (iii) above, please briefly explain.

20) Will the project involve repairs or maintenance of roads, trails, or firebreaks? Yes ___ No ___
If “yes” will the repairs or maintenance be solely routine? Yes ___ No ___
If you replied “no” to the preceding sub-question, please briefly explain.

21) Will the project involve any use of irradiated material or equipment: Yes ___ No ___
If “yes”, will such use be limited to one or more of the uses set forth below in (i) – (v): Yes ___ No
___

If you replied “no” to the preceding sub-question, please briefly explain.

(i) Use of gauging devices, analytical instruments, or other devices containing sealed radiological
sources.
(ii) Use of industrial radiography.
(iii) Use of radioactive material in medical or veterinary practices.
(iv) Possession of radioactive material incident to performing services such as installation,
maintenance, leak tests, and calibration.
(v) Use of uranium as shielding material in containers or devices, or radioactive tracers.
22) Will the project involve sampling, surveying, well drilling and installation, analytical testing, site
preparation, or intrusive testing? Yes ___ No ___
If “yes”, will the purpose of such work be limited to determining if hazardous wastes, contaminants,
pollutants, or special hazards (for example, asbestos, PCBs, lead-based paint, or unexploded ordnance)
are present? Yes ___ No ___
If you replied “no” to preceding sub-question, please briefly explain.

23) Will the project involve research, testing or operations? Yes ___ No ___
If “yes”, will the research, testing and operations be conducted:
i) solely at existing enclosed facilities? Yes ___ No ___
ii) consistent with previously established safety levels and in compliance with applicable federal,
state, and local standards? Yes ___ No ___
If you replied “no” to either sub-questions (i) or (ii) above, please briefly explain.