Project # _________________
SITE SPECIFIC CHECKLIST ENVIRONMENTAL CLEARANCE FORM (MUST BE KEPT IN INDIVIDUAL CLIENT FILES) Client Activity: Client Name: Location/Address of Site Reviewed:
1.
YES
NO
Is the structure over 50 years old?
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(If yes, is the intended activity exempted from SHPO review by a Programmatic Agreement in place?)
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(If yes, has the SHPO been notified of the project and requested to provide comments?)
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(If yes, is the property listed on or eligible for listing on the National Register of Historic Places?)
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(If yes, is the property located within or adjacent to an historic district?)
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(If yes, does the property’s area of potential effects include a historic district or historic property?)
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Historic Preservation [36 CFR Part 800]
If the answer to any of the previous 4 questions is “YES”, consultation with the SHPO is required and follow-up in accordance with 36 CFR Part 800. If consultation with the SHPO is required and follow-up in accordance with 36 CFR Part 800, has it been accomplished?
2.
Floodplain Management [24 CFR 55, Executive Order 11988] Is the project within the 100 year floodplain?
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If yes, an eight-step process mandated by Federal regulation must be followed. If the eight-step process is required, has it been accomplished?
Site Specific Checklist (SSC)
Revised: 10/09
Project # _________________
YES NO 3.
Wetland Protection [Executive Order 11990] Is the project within a recognized wetlands area?
4.
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1000 ft in any direction of a major highway (defined as 4 lanes, 2 lanes in each direction) or roadway (not a residential street)?
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3000 ft in any direction of a railroad?
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15 miles of a commercial airport?)
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Endangered Species Act [50 FR 402] Is there a likelihood of endangered species within the project area? If yes, consultation with the U.S. Fish and Wildlife Service is required to ensure that a proposed project will not jeopardize the existence of an endangered species or result in destruction or adverse impact to a cultural habitat for an endangered species If consultation is required, was it accomplished?
5.
Wild and Scenic Rivers Act [Sections 7(b), and (c)] Is the project in the vicinity of rivers in Colorado which are included in the national inventory of wild and scenic rivers? If yes, consultation with the National Park Service is required to determine whether or not the project will adversely affect the wild, scenic, or recreational value of the river. If consultation is required, was it accomplished?
HUD ENVIRONMENTAL STANDARDS 6.
Noise Abatement and Control [24 CFR Part 51B] Does the project involve housing or a facility in which people will be spending a lot of time (e.g. a day care center, nursing home, a hospital, or a senior center or library)? (If yes, is the project within:
If the answer to any of the previous 3 questions is “YES”, a determination is required to ensure the project meets the minimum standard for outside noise of 65 decibels or less. If a determination is required, has it been accomplished?
Site Specific Checklist (SSC)
Revised: 10/09
Project # _________________
7.
8.
YES NO Runway Clear Zones & Accident Potential Zones [24 CFR 51D] Is the project located within one mile of a commercial airport?
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If yes, will the project be built outside of runway clear zones?
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Explosive and Flammable Hazards [24 CFR 51C] Are there above-ground storage tanks (excluding residential fuel tanks), transmission pipelines, or loading facilities for hazardous liquids or gases within one mile of the project? If yes, a determination is required to ensure the project meets an Acceptable Separation Distance from potential hazards due to explosions, fires, or thermal radiation. If a determination is required, has it been accomplished?
9.
Toxic Chemicals and Radioactive Materials [HUD Notice 79-33] Is the project located on the U.S. EPA Superfund Program CERCLIS Site Location Listing?
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Regulatory Checklist (ref.: 24 CFR. Part 58.6 – Other requirements): _____ 24 CFR. Part 58.6(a): Flood Disaster Protection Act of 1973, as amended: (NOTE: Applicable only when project/activity site is located in a community participating in the National Flood Insurance Program, administered by the Federal Emergency Management Agency.) Is the project/activity located within a Special Flood Hazard Area (SFHA) as mapped by the Federal Emergency Management Agency (FEMA)?
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FEMA Map Number: _____________________________________________________ If the answer to this question is yes, the project/activity cannot proceed unless flood insurance is obtained through the National Flood Insurance Program. Insurance Policy Number: __________________________________________________
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24 CFR. Part 58.6(b): National Flood Insurance Reform Act of 1994, Section 582, (42 U.S.C. 5154a): (NOTE: Applicable only when the project site is located in an area where HUD disaster assistance is being made available.) Is the project located within a Special Flood Hazard Area (SFHA) as mapped by the Federal Emergency Management Agency (FEMA)?
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FEMA Map Number: _____________________________________________________
Site Specific Checklist (SSC)
Revised: 10/09
Project # _________________
If “Yes”, would the HUD disaster assistance be made to a person who had previously received Federal flood disaster assistance conditioned on obtaining and maintaining flood insurance and that person failed to obtain and maintain the flood insurance?
YES
NO
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If “Yes”, the HUD disaster assistance cannot be made to that person in the Special Flood Hazard Area to make a payment (including any loan assistance payment) for repair, replacement, or restoration for flood damage to any personal, residential, or commercial property. Insurance Policy Number: _________________________________________________
_N/A_ 24 CFR. Part 58.6(c): Coastal Barrier Improvement Act of 1990, as amended: (NOTE: Not applicable in the HUD Region VIII area. There are no coastal barriers identified in HUD Region VIII and in HUD Office of Native Americans, Northern Plains, States of CO, MT, NE, ND, SD, UT, and WY.)
_____ 24 CFR. Part 58.6(d): Civilian Airport Runway Clear Zone and/or Military Airport Clear Zone: (NOTE: Applicable only if the project/activity involves HUD assistance, subsidy, or insurance for the purchase or sale of an existing property in a Runway Clear Zone or Clear Zone pursuant to 24 CFR Part 51, Subpart D.) Does the project involve HUD assistance, subsidy, or insurance for the purchase or sale of an existing property in a Runway Clear Zone or Clear Zone pursuant to 24 CFR Part 51, Subpart D?
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Source documentation: ____________________________________________________ If yes, the responsible entity must advise the buyer that the property is in a runway clear zone or clear zone, what the implications of such a location are, and that there is a possibility that the property may, at a later date, be acquired by the airport operator. The buyer must sign a statement acknowledging receipt of this information. Comments: _____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Source Documentation: _________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
_______________________________________________________________________ Environmental Preparer name, title, and organization (printed or typed) _____________________________ Signed (Environmental Preparer)
Site Specific Checklist (SSC)
________________________ Date
Revised: 10/09
