Fill and Sign the Diving Medical Certificate 2010 Ucpa Form

Coastal Project Questionnaire and Certification Statement All questions must be answered. If you answer “Yes” to any of the questions, please call that specific department for further instructions to avoid delay in processing your application. Maps and plan drawings must be included with your packet. An incomplete packet will be returned. APPLICANT INFORMATION 1. 2. Name of Applicant Agent (or responsible party if other than applicant) Address Address City/State/Zip City/State/Zip _____________________________________________________________ Daytime Phone Daytime Phone Fax Number E-mail Address Fax Number E-mail Address PROJECT INFORMATION 1. This activity is a: new project modification or addition to an existing project If this is a modification, do you currently have any State, federal or local approvals Yes for this activity? ..................................................................................................................................... Note: Approval means any form of authorization. If "yes," please list below: Approval Type Approval# Issuance Date No Expiration Date ____________________________________ __________________ __________________ ________________ ____________________________________ __________________ __________________ ________________ ____________________________________ __________________ __________________ ________________ ____________________________________ __________________ __________________ ________________ ____________________________________ __________________ __________________ ________________ ____________________________________ __________________ __________________ ________________ If this is a modification, was this project reviewed for consistency with Alaska Coastal Yes Management? ........................................................................................................................................ No Previous State I.D. Number: AK ________________________________________________________________ Previous Project Name ________________________________________________________________________ PROJECT DESCRIPTION 1. Provide a brief description of your entire project and ALL associated facilities and land use conversions. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Revised 3/18/04 Page 1 Proposed starting date for project: _________________ Proposed ending date for project: ________________ 2. Attach the following: • a detailed project description, all associated facilities, and land use conversions, etc. (Be specific, including access roads, caretaker facilities, waste disposal sites, etc.); • a project timeline for completion of all major activities; • a site plan depicting project boundary with all proposed actions; • other supporting documentation to facilitate project review. Note: If the project is a modification, identify existing facilities and proposed changes on the site plan. PROJECT LOCATION 1. Attach a copy of the topographical and vicinity map clearly indicating the location of the project. Please include a map title and scale. Northwest Southcentral Southeast 2. The project is located in which region (see attached map): Southwest within or associated with the Trans-Alaska Pipeline corridor 3. Location of project (Include the name of the nearest land feature or body of water.) _____________________________ Township _______________ Range _______________ Section _______________ Meridian _________________ Latitude/Longitude _________________ / ________________ 4. Is the project located in a coastal district? Yes No USGS Quad Map ____________________________ If yes, identify: Select Nearest District (Coastal districts are a municipality or borough, home rule or first class city, second class with planning, or coastal resource service area.) Note: A coastal district is a participant in the State's consistency review process. It is possible for the State review to be adjusted to accommodate a local permitting public hearing. Early interaction with the district is important; please contact the district representative listed on the attached contact list. 5. Identify the communities closest to your project location: __________________________________________ 6. The project is on: State land or water* Federal land Private land Municipal land Mental Health Trust land *State land can be uplands, tidelands, or submerged lands to 3 miles offshore. See Question #1 in DNR section. Contact the applicable landowner(s) to obtain necessary authorizations. DEPARTMENT OF ENVIRONMENTAL CONSERVATION (DEC) APPROVALS Yes No 1. Will a discharge of wastewater from industrial or commercial operations occur? ................................ Will the discharge be connected to an approved sewer system? ........................................................... Will the project include a stormwater collection/discharge system? ..................................................... 2. Do you intend to construct, install, modify, or use any part of a wastewater (sewage or greywater) disposal system? ............................................................................................................ a) If the answer is yes, will the discharge be 500 gallons per day or greater?..................................... b) If constructing a domestic wastewater treatment or disposal system, will the system be located within fill material requiring a COE permit? ..................................................... If you answered yes to a) or b), answer the following: 1) What is the distance from the bottom of the system to the top of the subsurface water table? _________________________________________________________________________________ 2) How far is any part of the wastewater disposal system from the nearest surface water? ___________________________________________________________________________ Revised 3/18/04 Page 2 Yes No 3) Is the surrounding area inundated with water at any time of the year? ........................................... 4) How big is the fill area to be used for the absorption system? _______________________________________ (Questions 1 & 2 will be used by DEC to determine whether separation distances are being met; Questions 3 & 4 relate to the required size of the fill if wetlands are involved.) Yes No 5. Will your project require application of oil, pesticides, and/or any other broadcast Yes chemicals? ............................................................................................................................................ No 3. Will your project require a mixing zone? ............................................................................................ (If your wastewater discharge will exceed Alaska water quality standards, you may apply for a mixing zone. If so, please contact DEC to discuss information required under 18 AAC 70.032.) 4. a) Will your project result in construction, operation, or closure of a facility for solid waste disposal?...................................................................................................................... (Note: Solid waste means drilling wastes, household garbage, refuse, sludge, construction or demolition wastes, industrial solid waste, asbestos, and other discarded, abandoned, or unwanted solid or semi-solid material, whether or not subject to decomposition, originating from any source. Disposal means placement of solid waste on land.) b) Will your project result in treatment of solid waste at the site?..................................................... (Examples of treatment methods include, but are not limited to: incineration, open burning, baling, and composting.) c) d) e) Will your project result in storage or transfer of solid waste at the site?....................................... Will the project result in storage of more than 50 tons of materials for reuse, recycling, or resource recovery?..................................................................................................................... Will any sewage solids or biosolids be disposed of or land-applied to the site? ........................... (Sewage solids include wastes that have been removed from a wastewater treatment plant system, such as a septic tank, lagoon dredge, or wastewater treatment sludge that contain no free liquids. Biosolids are the solid, semi-solid, or liquid residues produced during the treatment of domestic septage in a treatment works which are land applied for beneficial use.) 6. a) b) c) d) e) f) g) h) i) Will you have a facility with industrial processes that are designed to process no less than five tons per hour and needs air pollution controls to comply with State emission standards? ....................................................................................................................... Will you have stationary or transportable fuel burning equipment, including flares, with a total fuel consumption capacity no less than 50 million Btu/hour? .................................... Will you have a facility with incinerators having a total charging capacity of no less than 1,000 pounds per hour?.......................................................................................................... Will you have a facility with equipment or processes that are subject to Federal New Source Performance Standards or National Emission Standards for hazardous air pollutants? .... 1) Will you propose exhaust stack injection? .............................................................................. Will you have a facility with the potential to emit no less than 100 tons per year of any regulated air contaminant?............................................................................................................. Will you have a facility with the potential to emit no less than 10 tons per year of any hazardous air contaminant or 25 tons per year of all hazardous air contaminants?....................... Will you construct or add stationary or transportable fuel burning equipment of no less than 10 million Btu/hour in the City of Unalaska or the City of St. Paul? .................................... Will you construct or modify in the Port of Anchorage a volatile liquid storage tank with a volume no less than 9,000 barrels, or a volatile liquid loading rack with a design throughput no less than 15 million gallons? .................................................................................. Will you be requesting operational or physical limits designed to reduce emissions from an existing facility in an air quality nonattainment area to offset an emission increase from another new of modified facility? ......................................................................................... 7. Do you plan to develop, construct, install, or alter a public water system?........................................... Revised 3/18/04 Page 3 8. a) b) c) Will your project involve the operation of waterborne tank vessels or oil barges that carry crude or non-crude oil as bulk cargo, or the transfer of oil or other Yes petroleum products to or from such a vessel or a pipeline system? ............................................... Will your project require or include onshore or offshore oil facilities with an effective aggregate storage capacity of greater than 5,000 barrels of crude oil or greater than 10,000 barrels of non-crude oil?............................................................................ Will you operate facilities on land or water for exploration or production of hydrocarbons? ........................................................................................................................... If you answered "No" to ALL questions in this section, continue to next section. No CPQ Contacts If you answered "Yes" to ANY of these questions, contact the DEC office nearest you for information and application forms. Please be advised that all new DEC permits and approvals require a 30-day public notice period. DEC Pesticide permits take effect no sooner than 40 days after the permit is issued. Based on your discussion with DEC, please complete the following: Types of project approvals or permits needed and name of individual you contacted. Date application submitted __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ Yes No 9. Does your project qualify for a general permit for wastewater or solid waste?..................................... Note: A general permit is an approval issued by DEC for certain types of routine activities. If you answered "Yes" to any questions in this section and are not applying for DEC permits, indicate reason: ______________________________________ (DEC contact) told me on _____________________ that no DEC approvals are required on this project because _____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Other: ____________________________________________________________________________________ __________________________________________________________________________________________ DEPARTMENT OF FISH AND GAME (DFG) APPROVALS 1. Is your project located in a designated State Game Refuge, Critical Habitat Area or Yes State Game Sanctuary? .......................................................................................................................... 2. Does your project include construction/operation of a salmon hatchery? ............................................. 3. Does your project affect, or is it related to, a previously permitted salmon hatchery?.......................... 4. Does your project include construction of an aquatic farm?.................................................................. If you answered "No" to ALL questions in this section, continue to next section. If you answered "Yes" to ANY questions under 1-4, contact the ADF&G Commercial Fisheries Division headquarters for information and application forms Revised 3/18/04 Page 4 No Based on your discussion with ADF&G, please complete the following: Types of project approvals or permits needed and name of individual you contacted. Date application submitted __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ If you answered "Yes" to any questions in this section and are not applying for ADF&G permits, indicate reason: ______________________________________ (ADF&G contact) told me on ___________________ that no ADF&G approvals are required on this project because __________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Other: ____________________________________________________________________________________ __________________________________________________________________________________________ DEPARTMENT OF NATURAL RESOURCES (DNR) APPROVALS 1. Is the proposed project on State-owned land or water or will you need to cross State-owned land for access? ("Access" includes temporary access for construction purposes. Note: In addition to State-owned uplands, the State owns almost all land below the ordinary high water line of navigable streams, rivers and lakes, and below the Yes mean high tide line seaward for three miles.) ........................................................................................................ No a) Is this project for a commercial activity? ........................................................................................ 2. Is the project on Alaska Mental Health Trust land (AMHT) or will you need to cross AMHT land? Note: Alaska Mental Health Trust land is not considered State land for the purpose of ACMP reviews. ................................. 3. Do you plan to dredge or otherwise excavate/remove materials on State-owned land?........................ Location of dredging site if different than the project site: _________________________________________ Township _______________ Range _______________ Section _______________ Meridian _________________ Latitude/Longitude _______________ / ______________ USGS Quad Map ________________________________ Yes No 4. Do you plan to place fill or dredged material on State-owned land? Location of fill disposal site if other than the project site: __________________________________________ Township _______________ Range _______________ Section _______________ Meridian _________________ Latitude/Longitude _________________ / ________________ Source is on: State Land Federal Land Private Land USGS Quad Map ____________________________ Municipal Land Yes No 5. Do you plan to use any of the following State-owned resources:.......................................................... Timber: Will you harvest timber? Amount: ____________________________________________________ Revised 3/18/04 Page 5 Materials such as rock, sand or gravel, peat, soil, overburden, etc.: Which material?___________________________________________ Amount: _______________________ Location of source: Project site Other, describe: _______________________________________ Township _______________ Range _______________ Section _______________ Meridian _________________ Latitude/Longitude ___________________ / __________________ USGS Quad Map ________________________ 6. Do you plan to divert, impound, withdraw, or use any fresh water, except from an existing Yes public water system or roof rain catchment system (regardless of land ownership)?............................ No Amount (maximum daily, not average, in gallons per day): ___________________________________________ Source: ___________________________ Intended Use: ___________________________________________ If yes, will your project affect the availability of water to anyone holding water rights to Yes that water? ............................................................................................................................................ 7. Do you plan to build or alter a dam (regardless of land ownership)? .................................................... 8. Do you plan to drill a geothermal well (regardless of land ownership)? ............................................... 9. At any one site (regardless of land ownership), do you plan any of the following?.............................. Mine five or more acres over a year's time Mine 50,000 cubic yards or more of materials (rock, sand or gravel, soil, peat, overburden, etc.) over a year's time Have a cumulative unreclaimed mined area of five or more acres If yes to any of the above, contact DNR about a reclamation plan. If you plan to mine less than the acreage/amount stated above and have a cumulative unreclaimed mined area of less than five acres, do you intend to file a voluntary reclamation plan for approval? ............................................................................................................................................ 10. Do you plan to explore for or extract coal? ........................................................................................... 11. a) Will you explore for or produce oil and/or gas?.............................................................................. b) Will you conduct surface use activities on an oil and/or gas lease or within an oil and/or gas unit?........................................................................................................................................... 12. Will you investigate, remove, or impact historical or archaeological or paleontological resources (anything over 50 years old) on State-owned land?............................................................... 13. Is the proposed project located within a known geophysical hazard area?............................................ Note: 6 AAC 80.900(9) defines geophysical hazard areas as “those areas which present a threat to life or property from geophysical or geological hazards, including flooding, tsunami run-up, storm surge run-up, landslides, snowslides, faults, ice hazards, erosion, and littoral beach process." "known geophysical hazard area" means any area identified in a report or map published by a federal, state, or local agency, or by a geological or engineering consulting firm, or generally known by local knowledge, as having known or potential hazards from geologic, seismic, or hydrologic processes. 14. Is the proposed project located in a unit of the Alaska State Park System? .......................................... 15. Will you work in, remove water or material from, or place anything in, a stream, river or lake? (This includes work or activities below the ordinary high water mark or on ice, in the active flood plain, on islands, in or on the face of the banks, or, for streams entering or flowing through tidelands, above the level of mean lower low tide.) Note: If the proposed project is located within a special flood hazard area, a floodplain development permit may be required. Contact the affected city or borough planning department for additional information and a floodplain determination.) .............. Revised 3/18/04 Page 6 No Name of waterbody: _________________________________________________________________________ Yes 16. Will you do any of the following:.......................................................................................................... Please indicate below: Build a dam, river training structure, other Build a bridge (including an ice bridge) Use a stream, lake or waterbody as a road instream impoundment, or weir Use water (even when frozen), or cross a stream with Pump water into or out of stream or lake tracked or wheeled vehicles, log-dragging or (including dry channels) excavation equipment (backhoes, bulldozers, Divert or alter a natural stream channel etc.) Change water flow or the stream channel Install a culvert or other drainage structure Introduce silt, gravel, rock, petroleum Construct, place, excavate, dispose or remove products, debris, brush, trees, chemicals, or any material below the ordinary high water of other organic/inorganic material, including a waterbody Construct a storm water discharge or drain waste of any type, into water Alter, stabilize or restore banks of a river, into a waterbody Place pilings or anchors stream or lake (provide number of linear feet Construct a dock affected along the bank(s) Mine, dig in, or remove material, including Construct a utility line crossing Maintain or repair an existing structure woody debris, from beds or banks of a Use an instream in-water structure not waterbody Use explosives in or near a waterbody mentioned here No If you answered "No" to ALL questions in this section, continue to next section. If you answered "Yes" to ANY questions under 1-16, contact the Area DNR, office for information and application forms. CPQ Contacts Based on your discussion with DNR, please complete the following: Types of project approvals or permits needed and name of individual you contacted. Date application submitted __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ __________________________________________________________ ______________________________ If you answered "Yes" to any questions in this section and are not applying for DNR permits, indicate reason: _________________________________ (DNR contact) told me on ______________________ that no DNR approvals are required on this project because _________________________________________________ _________________________________________________________________________________________ FEDERAL APPROVALS U.S. Army Corps of Engineers (COE) 1. Will you dredge or place structures or fills in any of the following: Yes tidal (ocean) waters? streams? lakes? wetlands*? ................................................................................. If yes, have you applied for a COE permit? .................................................................................... No Date of submittal: ________________________________________________________________________ Name of COE contact: ____________________________________________________________________ (Note: Your application for this activity to the COE also serves as application for DEC Water Quality Certification.) Revised 3/18/04 Page 7 *If you are not certain whether your proposed project is in a wetlands (wetlands include muskegs), contact the COE, Regulatory Branch at 907-753-2712 for a wetlands determination (outside the Anchorage area call toll free 1-800-478-2712) Bureau of Land Management (BLM) Yes 2. Is the proposed project located on BLM land, or will you need to cross BLM land for access?........... If yes, have you applied for a BLM permit or approval? ................................................................ No Date of submittal: _________________________________________________________________________ Name of BLM contact: _____________________________________________________________________ U.S. Coast Guard (USCG) 3. a) Do you plan to construct a bridge or causeway over tidal (ocean) waters, or navigable rivers, Yes streams or lakes?.............................................................................................................................. b) Does your project involve building an access to an island? ............................................................ c) Do you plan to site, construct, or operate a deepwater port?........................................................... If yes, have you applied for a USCG permit? ........................................................................... No Date of submittal:______________________________________________________________________ Name of USCG contact: ________________________________________________________________ U.S. Environmental Protection Agency (EPA) Yes 4. a) Will the proposed project have a discharge to any waters?............................................................. b) Will you dispose of sewage sludge (contact EPA at 206-553-1941)? ............................................ If you answered yes to a) or b), have you applied for an EPA National Pollution Discharge Elimination System (NPDES) permit? ..................................................................................... No Date of submittal:______________________________________________________________________ Name of EPA contact: __________________________________________________________________ c) (Note: For information regarding the need for an NPDES permit, contact EPA at 1-800-424-4372) Will construction of your project expose more than one acre of soil? (This applies to the total amount of land disturbed, even if disturbance is distributed over more than one season, and also applies to areas that are part of Yes a larger common plan of development or sale.) ............................................................................................... d) Is your project an industrial facility that will have stormwater discharge directly related to manufacturing, processing, or raw materials storage areas at an industrial plant?.......... If you answered yes to c) or d), your project may require an NPDES Stormwater permit. Contact EPA at 206-553-8399. Federal Aviation Administration (FAA) 5. a) Is your project located within five miles of any public airport?...................................................... b) Will you have a waste discharge that is likely to decay within 5,000 feet of any public airport? ............................................................................................................................................ If yes, please contact the Airports Division of the FAA at 907-271-5438. Federal Energy Regulatory Commission (FERC) 6. a) Does the project include any of the following: 1) a non-federal hydroelectric project on any navigable body of water........................................ 2) a location on federal land (including transmission lines) ......................................................... 3) utilization of surplus water from any federal government dam ................................................ b) Does the project include construction and operation, or abandonment of natural gas pipeline facilities under sections (b) and (c) of the Federal Power Act (FPA)?............................................ Revised 3/18/04 Page 8 No c) Does the project include construction for physical interconnection of electric transmission Yes facilities under section 202 (b) of the FPA? .................................................................................... If you answered yes to any questions under number 6, did you apply for a permit from FERC?....................................................................................................................................... No Date of submittal: _____________________________________________________________________ Name of FERC contact: _________________________________________________________________ (Note: For information, Div. Hydropower-Environment and Engineering contact: Vince Yearek 202-502-6174 or Mike Henry 503-9446762, 202-502 8700; (for Natural Gas Projects) Division of Pipeline Certificate 202-502-8625; for Alaska projects contact Richard Foley – 202-502-8955) U.S. Forest Service (USFS) Yes 7. a) Does the proposed project involve construction on USFS land? .................................................... b) Does the proposed project involve the crossing of USFS land with a water line?.......................... If the answer to either question is yes, did you apply for a USFS permit or approval?............ No Date of submittal: _____________________________________________________________________ Name of USFS contact: _________________________________________________________________ Yes No 8. Have you applied for any other federal permits or authorizations? ....................................................... AGENCY APPROVAL TYPE __________________________________________ __________________________________________ __________________________________________ __________________________________________ DATE SUBMITTED ______________________ ______________________ ______________________ ______________________ _____________________ _____________________ _____________________ _____________________ Please be advised that the CPQ identifies permits subject to a consistency review. You may need additional permits from other agencies or the affected city and/or borough government to proceed with your activity. Certification Statement The information contained herein is true and complete to the best of my knowledge. I certify that the proposed activity complies with, and will be conducted in a manner consistent with, the Alaska Coastal Management Program. ___________________________________________________ ____________________________ Signature of Applicant or Agent Date Note: Federal agencies conducting an activity that will affect the coastal zone are required to submit a federal consistency determination, per 15 CFR 930, Subpart C, rather than this certification statement. ACMP has developed a guide to assist federal agencies with this requirement. Contact ACMP to obtain a copy. This certification statement will not be complete until all required State and federal authorization requests have been submitted to the appropriate agencies. To complete your packet, please attach your State permit applications and copies of your federal permit applications to this questionnaire. Revised 3/18/04 Page 9