3150-PM-BWEW0050 7/2016
    Form
     
    3150-PM-BWEW0051 Rev. 8/2016
    Checklist
     

     

    3150-PM-BWEW0051 Rev. 8/2016
    Checklist


     
    COMMONWEALTH OF PENNSYLVANIA
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
    DEP USE ONLY
          Non-Reporting
          Reporting  

    PASPGP-5 REPORTING CRITERIA CHECKLIST

    The following questionnaire must be completed (instructions on pages 1-6) and submitted as part of all DEP Chapter 105 applications / registrations to determine the appropriate Federal Pennsylvania State Programmatic General Permit-5 (PASPGP5) review procedure. Incomplete submissions, including lack of certification signature, will be returned.

    Applicant / Project Name:       County(s):        

    SECTION A: ELIGIBILITY DETERMINATION
    YES   NO
    1.   Does the proposed work associated with the Single and Complete Project temporarily and/or permanently impact greater than 1.0 acre of waters and/or wetlands, and/or result in the loss of greater than 1,000 linear feet of stream channel(s)?
    YES   NO
    2.   Is any of the proposed work located waterward of the ordinary high water mark (OHWM) of any of the ineligible waterbodies identified in the instructions?
    YES   NO
    3.   Has any portion of the proposed work been denied a DEP Chapter 105 Permit, a State Water Quality Certification as required under Section 401 of the Clean Water Act, or a Coastal Zone Consistency Determination?
    YES   NO
    4.   Does the proposed work result in the diversion of more than 10,000 gallons per day of surface water or groundwater into or out of the Great Lakes Basin (Lake Erie Watershed)?
    *****
    SECTION B: REPORTING ACTIVITY DETERMINATION
    YES   NO
    1.   Does the proposed work associated with a Single and Complete Project, including any attendant features, permanently and/or temporarily impact greater than 0.5 acre of waters of the United States, including jurisdictional wetlands?
    YES   NO
    2a.   Does the application/registration include any proposed Single and Complete Projects permanently impacting greater than 250 linear feet of streams, rivers, or other watercourses (excluding wetlands)?
    YES   NO
    2b.   Is the Single and Complete Project for stream bank stabilization, rehabilitation, protection and/or enhancement and propose impacts of greater than 500 linear feet of stream channel(s)?
    YES   NO
    2c.   Does the Single and Complete Project qualify for DEP GP-1 for Fish and Enhancement Structures?
    YES   NO
    2d.   Is the project covered by a programmatic State Water Quality Certification issued by DEP - that is conditioned upon receiving approval by- the Environmental Review Committee?
    YES   NO
    3.   Does the application/registration include any Single and Complete Projects that propose the permanent conversion of greater than 0.10 acre of forested and/or shrub-scrub wetlands in association with a regulated activity?
    YES   NO
    4.   If the application/registration is for a utility line, do any of the single and complete projects in waters of the United States, including jurisdictional wetlands, exceed 500 linear feet (excluding overhead lines)?
    YES   NO
    5.   Is this application/registration to place a buried utility line in waters and/or wetlands in a manner that the utility line will run parallel to or along a stream bed?
     

     

     

    SECTION B: REPORTING ACTIVITY DETERMINATION (CONT)
    YES   NO
    6.   Is the application/registration associated with a Single and Complete Project whereby a previous Department of the Army authorization has been issued through an Individual Permit, a Nationwide Permit, or a PASPGP processed by the Corps as a Category III/Reporting Activity? If YES, please complete the following table.
    Authorization
    Type
    Authorization
    Number
    Date
    (mm/dd/yyyy)

    Federal Permitted Impacts  
           
    Wetlands
    Waters
     
         
         
         
         
         
     
         
         
         
         
         
     
         
         
         
         
         
     
         
         
         
         
         
     
         
         
         
         
         
     
    YES   NO
    7a.   Is the proposed project located in waterways occupied by Federally listed, proposed, or candidate mussels or fish, or in waters of the United States within 300 feet of these listed waterways? See instructions for list of waterways.
    YES   NO
    7b.   If 7a is yes, have you received documented clearance from the USFWS, or a Section 7 of the Endangered Species Act (ESA) “no effect” determination from the Corps? Documented clearance from the USFWS could include PNDI language stating “NO KNOWN IMPACT”; or, if in a USFWS letter the language must indicate “no effect” or “the project or activity will not affect Federally listed species.”
    YES   NO
    8a.   Does the project propose impacts to Federally regulated wetlands in a county that requires bog turtle screening procedures? See instructions for list of counties.
    YES   NO
    8b.   If 8a is YES, have you received documented clearance from the USFWS, or a Section 7 ESA “no effects” determination from the Corps? Documented clearance from the USFWS could include PNDI language stating “NO KNOWN IMPACT”; or, if in a USFWS letter the language must indicate “no effect” or “the project or activity will not affect Federally listed species.”
    YES   NO
    9a.   Does the completed Pennsylvania Natural Diversity Inventory (PNDI) search receipt identify a potential conflict(s) for a Federally listed species?
    YES   NO
    9b.   If YES for 9a, have you received additional documented Section 7 ESA clearance, or do you agree, through signing of the PNDI receipt, to comply with all avoidance measures identified on the PNDI receipt associated with Federally listed species for the proposed work?
    YES   NO
    10.   Is the proposed work associated with maintenance dredging of a reservoir’s design storage capacity, including the removal of accumulated sediments? This corresponds to activities authorized pursuant to Section 7 of the Dam Safety and Encroachments Act (DSEA), 32 P.S. § 693.1, et seq., and the rules and regulations promulgated there under in the PA Bulletin (codified at 25 PA. Code, Chapter 105, § 105.131(c)).
    YES   NO
    11a.   If the DEP Chapter 105 application/registration requires submittal of a Cultural Resources Notification Form as part of the application/registration, have you included the response letter from the State Historic Preservation Officer (SHPO), i.e., Pennsylvania Historic and Museum Commission (PHMC) with your application/registration?
    YES   NO
    11b.   Has the PHMC determined that archaeological or other cultural resources are believed to exist within the permit area?
    YES   NO
    11c.   If yes for 11b, have you received follow-up documented clearance from PHMC, or a Section 106 “no effect” determination from the Corps?
    YES   NO
    12a.   Does the proposed work occur in a component of the National Wild and Scenic River System or in a river officially designated by Congress as a “Study River” for possible inclusion in the System? See instructions for listing.
    YES   NO
    12b.   If yes for 12a, have you received a written determination from the Federal agency with direct management responsibility for such river that the proposed activity will not adversely affect any Wild and Scenic River including study rivers?
    YES   NO
    13.   Does the proposed project require the preparation of an Environmental Impact Statement?
    YES   NO
    14.   Does the proposed regulated activity or area of indirect impact (secondary impact) extend across state boundaries (i.e., the work in not wholly located within the Commonwealth of Pennsylvania)?
     

     
     

    SECTION B: REPORTING ACTIVITY DETERMINATION (CONT)
    YES   NO
    15.   Is the proposed work authorized pursuant to DEP Chapter 105 permits in conjunction with coal and non-coal mining permits issued by the DEP District Mining Offices (Bureau of Mining and Reclamation), including activities authorized pursuant to Chapter 105 Waiver 4 [25 Pa. Code §105.12(a)(4)] and GP-101 and GP-102]?
    YES   NO
    16.   Is the proposed work associated with the construction of a Mitigation Bank or In Lieu Fee site developed to meet the requirements of the Corps and EPA April 10, 2008 Compensatory Mitigation for Losses of Aquatic Resources: Final Rule?
    YES   NO
    17.   Will the proposed work alter, use, build upon, attempt to possess, or that may harm or impair any existing or proposed Corps Civil Works project, and any Corps-owned or managed property?
    YES   NO
    18a.   Does the Single and Complete Project involve the construction or expansion of a residential, commercial or institutional subdivision or development?
    YES   NO
    18b.   Does greater than 0.25 acre of wetland(s) exist within the property boundary that are not proposed to be directly impacted as part of this application/registration? If YES, provide wetland acreage:       acres.
    YES   NO
    18c.   Are you proposing to protect the wetland area(s) through a deed restriction or conservation easement that follows the Corps’ Model Protective Covenant?
    YES   NO
    19.   Does the proposed work temporarily impact waters and/or wetlands that will remain in place for more than 1 year?
    YES   NO
    20.   Do you have any other pending applications/registrations with the DEP or Corps that are necessary for this total proposed project to function and meet its intended purpose? If YES, provide following information.
    Application / Registration Number / Type
    Project Name
    Date of Submittal to DEP
    (mm/dd/yyyy)
    DEP / CCD
    Reviewing Office
    Corps
    Reviewing Office
     
         
         
         
         
         
     
         
         
         
         
         
     
         
         
         
         
         
     
         
         
         
         
         
     
         
         
         
         
         
     
    YES   NO
    21.   Are you proposing to do work in the Delaware River (upstream from the U.S. Route 202 Bridge in New Hope, Pennsylvania.) and/or the Lehigh River (from the mouth to Francis E. Walter Dam, located in Carbon and Luzerne County, Pennsylvania between March 15 and June 30?
    YES   NO
    22a.   Does the proposed work occur in any of the waters listed in the instructions?
    YES   NO
    22b.   Will you comply with all of the identified conservation measures?
    *****
     

     
     
     
     
     
     
     
     
     
     
     
     
     
     

    SECTION C: CERTIFICATION

    I certify that the information provided on this form is true and correct to the best of my knowledge and information. If any of the information and/or plans is found to be in error, falsified, and/or incomplete, your Chapter 105/PASPGP-5 authorization/verification may be subject to modification, suspension, or revocation in accordance with applicable regulations.

     
               

      Signature of Applicant   Date

     
           
      Name Typed or Printed
     

    *****

    IMPERVIOUS SURFACE DATA FOR CORPS

     

     

    YES   NO
    1a.   Is your project located in the Corps of Engineers Philadelphia District (Delaware River Watershed), or in Chester, Lancaster, or York County?
    YES   NO
    1b.   Does your project propose impervious surfaces within waters and wetlands? If YES, provide area of impervious surface within the footprint of waters and wetlands:           square feet
    YES   NO
    1c.   Does any part of your project propose the removal of any impervious surfaces? If YES, provide area of impervious surface being removed:           square feet
     

    FOR DEP USE ONLY
     
     
               

      DEP / District Manager Signature   Date
     
     
                     
      Name Typed or Printed   Permit Number

     

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