1. CHAPTER 105 ENVIRONMENTAL ASSESSMENT FORM

3150-PM-BWEW0017A Rev. 6/2017
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
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CHAPTER 105 ENVIRONMENTAL ASSESSMENT FORM
Included
Item
Location
Note: The Department may waive a specific information requirement in writing, at the request of the
Applicant, during the pre-application review process if the Department determines the information is not
necessary to complete the review.
Module S1: Project Summary
This module is intended to organize information in order to present an overall summary of the project scope, certain key information
requirements and when applicable, a comprehensive view of the overall project and related projects.
A.
Provide an overall project description and If the answer to the question below is
YES
, address CEA
requirements; otherwise proceed to
S1.B
Comprehensive Environmental Assessment (CEA) when applicable.
Answer the following question:
Does the "overall" project require more than one Ch. 105 permit in more than one county
or will the project be completed in more than one phase?
Yes
No
B. Provide information related to the project purpose, need, water dependency and summarize the amount and
type of resources present and the temporary and permanent impacts proposed to those resources.
Module S2: Resource Identification and Characterization
This module is intended to organize information related to the identification of the resources present on the project site and to characterize
those resources that may be affected by the proposed project.
A. Provide the standard resource identification information, location map, wetland determination or delineation
reports; watercourse reports; identification and qualifications of preparers; location map, and answer the related
questions.
Is the site located within or adjacent to any of the following; or within 100 feet of items vii or viii?
i.
National, state or local park, forest or recreation area
Yes
No
ii.
National natural landmark
Yes
No
iii. National wildlife refuge, or Federal, state, local or private wildlife or plant sanctuaries
Yes
No
iv. State Game Lands
Yes
No
v.
Areas identified as prime farmland
Yes
No
vi. Source for a public water supply
Yes
No
vii. A National Wild or Scenic River or the Commonwealth’s Scenic Rivers System
Yes
No
viii. Designated Federal wilderness area
Yes
No
B. Identify all aquatic resources present on the project site and provide an identifier, the resource type; size of the
resource(s); fishery designations, Ch. 93 uses and special protection status; and Exceptional Value (EV) wetland
analysis.
C. Provide the following information related to habitat for Federal threatened and endangered (T&E) plant and
animal species or State T&E species or species of special concern - copies of search forms or search receipts;
identification of avoidance and minimization efforts taken to resolve identified conflicts.
Did the PNDI search or agency coordination identify any potential conflicts?
Yes
No
If the above is answered
YES
; answer the following two questions related to PNDI Coordination:
a.
Is the applicant utilizing a sequential review of the PNDI coordination?
Yes
No
b.
Is the applicant utilizing a concurrent review of the PNDI coordination?
Yes
No
D. Characterize the aquatic resources: riverine, wetland and lacustrine present on the project site that are proposed
to be directly or indirectly affected by the project. Including but not limited to the following, resource classification
information, Level 2 rapid condition assessment results, discussion of resource functions, characterization of
riparian properties and any other relevant information or studies conducted.
Module S3: Identification and Description of Potential Project Impacts
This module is intended to organize and present information concerning the potential impacts or effects of the proposed project
in this
application. Impacts related to the "over all" project that are proposed under related but separate application(s) should be addressed as
part of the CEA Policy response under
S1.A
.
A. Provide a summary table of the proposed temporary and permanent direct and indirect impacts for each effected
resource category (e.g. riverine, wetlands and lacustrine resources).
B.
If any questions from
S2.A
Standard Information Response questions were answered YES, discuss in detail
any potential impacts to those resource(s).
IMPORTANT NOTE: If either item vii or viii from S2.A is answered YES, the project is not eligible as a "Small
Project Application" type. Complete all applicable sections of the EA form for the standard application
type unless an item was otherwise waived by the Department in writing (see previous Note on waiving of
information requirements).

3150-PM-BWEW0017A Rev. 6/2017
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Included
Item
Location
C. Provide a table(s) of all proposed water obstruction(s), encroachment activities and dams (e.g. subfacility codes)
and provide an identifier, the subfacility code and description, resource identifier from
S2.B
, latitude and
longitude, the proposed temporary and permanent direct and indirect impacts and subfacility details.
D. Provide a discussion of how the proposed subfacility(ies) individually and in combination directly and/or indirectly
impact the identified resource(s) and the effects on the applicable resource functions: hydrologic,
biogeochemical, habitat, recreation, any other environmental impacts and the effects on the property or riparian
rights of owners upstream, downstream or adjacent to the project.
E.
Antidegradation Analysis
- The applicant should demonstrate consistency with State antidegradation
requirements as described in the Water Quality Antidegradation Implementation Guidance Policy Document
Number 391-0300-002.
Project application information provided below in
S3.F, G and H
may be
cross-referenced.
F.
Alternatives Analysis
- The scope and extent of this analysis should be commensurate with the size and scope
of the proposed project impacts
in this
application, information provided in
S4.A
below, related to avoidance and
minimization efforts, may be cross-referenced.
G.
Potential Secondary Impact Evaluation
- Identify and describe environmental impacts on adjacent land and
water resources associated with but not that direct result of the project.
H. Identify and evaluate the potential cumulative environmental impacts of this project and other potential or existing
projects like it, and the impacts that may result through numerous piecemeal changes to the wetland resource.
Module S4: Mitigation Plan
This module is intended to organize and present information concerning actions undertaken in accordance with the definition of
Mitigation
in Title 25 Pa. Code Chapter 105 -
§
105.1, 105.16, 105.18a(a)(3), 105.18a(b)(7), 105.20a, and 105.21 as related to the
potential impacts or effects of the proposed project
in this
application.
A. Identify and discuss any measures taken that resulted in avoiding or minimizing unavoidable resource impacts,
provide detailed responses for individual proposed impact area(s)
and
the project as a whole.
B. Identify and discuss any repair, rehabilitation or restorative actions taken to rectify an impacted resource, provide
detailed responses for individual proposed impact area(s) and the project as a whole. Identify and discuss any
proposed preservation and maintenance operations that will be taken to reduce or eliminate an impact during
the life of the project.
C. Identify and discuss any actions undertaken to provide compensatory mitigation including the purchase of credits
from an approved provider, a detailed discussion of proposed compensation actions and how they will offset the
lost resource functions. Provide detailed plans including performance standards and success criteria.
Answer the following question. If the answer to the question is
YES
, provide the information regarding the
mitigation credit provider; otherwise provide a detailed mitigation plan. If the application proposes to utilize both
mitigation bank credits and conduct permittee responsible mitigation; both the credit provider and mitigation plan
information shall be submitted.
Does the applicant propose to utilize an approved mitigation bank to provide all or a
portion of the compensation?
Yes
No
D.
When applicable, provide a plan to monitor the identified actions proposed in
S4.B
and/or
S4.C
compensatory
mitigation area.
Applicants should utilize the Department's Design Criteria and the USACE's RGL
08-03 -(http://www.usace.army.mil/Portals/2/docs/civilworks/RGLS/rgl08_03.pdf) to develop monitoring plans
for compensatory mitigation proposals. The plan should include performance standards/success criteria,
duration and timeframes of monitoring, monitoring report template, and template remedial action or adaptive
management plan.
Note: All or portions of this Module may apply to "Small Project" type applications under case specific circumstances and
should be discussed during any pre-application meetings or prior to application submittal.
CERTIFICATION
I certify that the above statements, attachments including those labeled and identified as Enclosures, and all conclusions are true, correct,
and based upon current environmental principles and science, to the best of my knowledge and belief.
Signature
Date

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