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2015 MDT UTILITY OCCUPANCY LOCATION AGREEMENT Montana Department of Transportation MDT•ROWUTL-967 05r14 UTILITY OCCUPANCY AND LOCATION AGREEMENT Page 1 of 2 Completed By Utility Completed By Montana Department of Transportation Date Submitted: Route: Work Order Number: Date Recived: Maintenance No: Applicant/utility: Jefferson County Agreement No:: Address: PO Box H Telephone: (406) 225-4065 Project No.: City: Boulder State MT zip: 59632 Designation: Email: jshephard@jeffersoncounty-mt.gov UPN.: Facility Desc iptione 1) Overhead Facilities: size: NIA Type: NIA 2) Underground Facilities: Size: 6" PVC Type: Sanitary Sewer Service 3) Other: Location: Route: WCentennial Ave CO22206 1) Longitudinal: N/A feet from N ❑ S ❑ E ❑ W❑ RNV line from milepost(station) N/A to milepost(station) N/A 2) Centerline crossing at milepost(station): 600 feet west of route beginning - local route, not stationed 3) Downguys not in parallel with the roadway at milepost(s): N/A 4) Section 29 Township 6 N Range 4 W County Jefferson Submit this agreement in triplicate and attach• a. Construction Prints. (Highway prints preferred.) Distances from RM line, centerline and existing utilities, to the proposed installation. b. Environmental Checklist(MDT-ENV-006) The utility will notify in hone at least 8 hours in advance of any work detailed in this Agreement, except for emergency situatons. er completing the work, the applicant must submit a Form UTL 968(attached)for approval. This installation is subject to compliance with the Administrative Rules of Montana 18.7.201 through 18.7.232,the Utility Occupancy Guidelines,the Manual on Uniform Traffic Control Devices and the following requirements: Additional Requirements This application will be considered complete when all impacts associated with the requested action have been reviewed and approved by all agencies affected by this action. The applicant is responsible for obtaining these necessary approvals. This agreement is subject to the terms and conditions shown on Page 2. Applicant/Utility Jefferson County By: Print Name: Title: Montana Department of Transportation By: Date Approved: Title: Montana Department of Transportation UTILITY OCCUPANCY MDT-ROWUTL-967 05114 AND LOCATION AGREEMENT Page 2 of 2 Terms and Conditions: The Jefferson County hereinafter referred to as the"APPLICANT,"and the Montana Department of Transportation,hereinafter refereed to as the-STATE,"hereby agree as follows: 1. FEE. The process fee for issuance of this agreement is 2. STATE SAVED HARMLESS FROM CLAIMS. As a consideration of being issued this agreement,the APPLICANT, its successors or assigns,agrees to protect the STATE and save it harmless from all claims,actions or damage of every kind and description which may accrue to,or be suffered by,any person or persons,corporations or property by reason of the performance of any such work,character of materials used,or manner of installations,maintenance and operation,or by the improper occupancy of said highway right-of-way,and in case any suit or action is brought against the STATE and arising out of, or by reason of, any of the above causes,the APPLICANT, its successors or assigns,will,upon notice to them of the commencement of such action,defend the same at its sole cost and expense and satisfy any judgment which may be rendered against the STATE in any such suit or action. 3. PROTECTION OF TRAFFIC. The APPLICANT shall protect the work area with traffic control devices that comply with the Manual of Uniform Traffic Control Devices. The APPLICANT may be required to submit a traffic control plan to the District Utility Engineering Specialist for approval prior to starting work. During work,the District Utility Engineering Specialist or designee may require the APPLICANT to use additional traffic control devices to protect traffic or the work area. No road closure shall occur without prior approval from the District Administrator.All workers within the right-of-way of a Federal-aid highway who are exposed either to traffic(vehicles using the highway for purposes of travel)or to construction equipment shall wear high-visibility class 2 or 3 safety apparel. For nighttime activity,the flagger(s)shall wear class 3 safety apparel. APPLICANT shall provide flagger(s)who are currently certified by the Montana flagger training program;the ATSSA flagger program;or the Idaho,Oregon, or Washington state flagger training programs. 4. HIGHWAY AND DRAINAGE. If the work done under this agreement interferes in any way with the drainage of the STATE highway affected, APPLICANT shall,at the APPLICANTS expense,make such provisions as the STATE may direct to remedy the interference. 5. RUBBISH AND DEBRIS. Upon completion of work,all rubbish and debris shall be immediately removed and the roadway and roadside left in a neat and presentable condition satisfactory to the STATE. 6. INSPECTION. The installation shall be in compliance with the attached plan and the conditions of this agreement. The APPLICANT may be required to remove or revise the installation,at sole expense of APPLICANT, if the installation does not conform with the requirements of this agreement or the attached plan. 7. REMOVAL OF INSTALLATIONS OR STRUCTURES. Unless waived by the STATE,upon termination of this agreement, the APPLICANT shall remove the installations or structures installed under this agreement at no cost to the STATE and restore the premises to the prior existing condition,reasonable and ordinary wear and tear and damage by the elements,or by circumstances over which the APPLICANT has no control,excepted. 8. MAINTENANCE AT EXPENSE OF APPLICANT. APPLICANT shall maintain,at its sole expense,the installations and structures for which this agreement is granted,in a condition satisfactory to the STATE. 9. STATE TO BE REIMBURSED FOR REPAIRING ROADWAY. Upon being billed,APPLICANT agrees to promptly reimburse STATE for any expense incurred in repairing surface of roadway due to settlement at installation,or for any other damage to roadway as a result of the work performed under this agreement. 10. The APPLICANT shall not discharge or cause discharge of any hazardous or solid waste by the installation or operation of the facility of a STATE Right-of-Way. 11. The APPLICANT will control noxious weeds within the disturbed installation area for two(2)years. 12. In accordance with Mont.Code Ann.§763403(2),APPLICANT shall,at APPLICANT's expense,employ the services of a Montana Licensed Professional Land Surveyor to re-establish all existing survey monuments disturbed by work contemplated under this agreement. 13. The use of explosives is prohibited for the installation. 14. Any condition of this agreement shall not be waived without written approval of the appropriate District Administrator. The average turnaround time for a completed application is 30 working days. If the proposed installation will result in significant, permanent,or long term impacts to the transportation network additional review time may be necessary. Jefferson Co. New Clerk&Recorder Building Environmental Checklist Supplement 1. The project involves constructing a new building on County-owned property,adjacent to the existing courthouse building. Water and sewer services will be connected to existing water and sewer mains. The proposed sewer service will be installed beneath W Centennial Ave.,an MDT- maintained local route. No historical or archaeological sites are known to exist within the construction limits. The adjacent courthouse building will not be impacted by the project. 2. The project involves construction within existing,fully developed land and right-of-way. No parklands,recreation areas,wildlife or waterfowl refuges will be impacted. 3. The project involves construction within existing,fully developed land and right-of-way. No farmlands will be impacted. 4. A) Construction of sewer service will involve temporary closure of W Centennial Ave.and a one block detour. Adverse impacts will be temporary and negligible. B) Project has received preliminary approval from the City of Boulder 7. See attached maps. 8. Construction will cause temporary adverse impacts to noise level and air quality typical of small building construction. Adverse impacts will be temporary and negligible. 10. See attached map. 11. A) See attached map and list of species of concern. B) No adverse impacts are anticipated due to the project being located well within the City of Boulder. 14. Construction of sewer service will involve temporary closure of W Centennial Ave., an MDT- maintained local route,and a one block detour. Adverse impacts will be temporary and negligible. Other forms of transportation will not be impacted. 15. The project involves constructing a new building on County-owned property,adjacent to the existing courthouse building. Local building and occupancy permits will be required. 16. The project involves constructing a new building on County-owned property,adjacent to the existing courthouse building. Water and sewer services will be connected to existing water and sewer mains. The proposed sewer service will be installed beneath W Centennial Ave.,an MDT- maintained local route. Nonattainment Areas Areas that violate federal air quality standards are designated nonattainment areas. EPA declares each area nonattainment for a specific pollutant such as carbon monoxide, particulate matter, etc. Nonattainment areas for different pollutants ntay overlap each other or share common boundaries. Montana has 13 official nonattainment areas with 2 additional areas under an EPA'SIP Calf(Billings for S02 and Kalispell for CO). Eleven of these nonattainment designations are under state jurisdiction, and the other three are on Native American reservations with tribal/EPA jurisdiction.Montana's nonattammernt areas include 13 communities,three of which violate standards for more than one pollutant. Particulate matter is the most common cause of nonattainment in Montana. DEQ has worked, and will continue to work, with communities and industries in each nonattainment area to develop a State Implementation Plan(a control plan)that will bring the area back into compliance with the r atnmya federal ambient air quality standards.These plans require an inventory of u , '. 2 Bwo all emission sources of the relevant pollutant in the area. DEQ then meets ; �m s s East ralb with each community to determine the best control shat a liar(tFalls strategies for that ,t n s caeca rata. community,but the community has the final say on which control e• a Kalispell 7 Lama nppr(Tn"v&MA) strategies will be implemented. tea+ 9 Lemon ., ..4 y 'r .d {` °T t..o-yv�.t` vy to Missoula ' k''F , . •.. It Pnnaall(7nnW1aPA) 12 n""(Trlbs.MA) to '- • .:: .. .,� 17 Thompson Pall. Most sources -- Attalnmlent >'_ a wheae h contributing to lead } / 1 Air Quality NonattaimnatATM and sulfur dioxide Area is desiggate7et,as attainment osttena the control r�co •sox nonattainment technoIo ofj? tartta, A BAGT •rh s Trod° X, problems in awtata b source to be Montana are app[(tvlj¢; agency on Industrial sources a ep., cu�uen located in the East �' Helena and Billings/Laurel areas. Sources contributing to the carbon monoxide nonattainment status in Missoula,Billings, and Great Falls include vehicle emissions, wood taming sources, and industrial emissions. Particulate matter nonattainment is often the result of excessive road dust, wood burning sources, and industrial emissions. Many of Montana's nonattainment areas are valley communities,and the state's topography and weather play a big role in their failure to attain the air quality standards. Narrow valleys restrict good dispersion of pollutants, especially during winter,when low winds can cause atmospheric temperature inversions. Inversion'complicate the impact of air pollution by trapping pollutants in cold air along valley floors under a layer of warm air.Inversions can last for several days and sometimes longer than a week. Prevention of Significant Deterioration Area Classification Prevention of Significant Deterioration(PSD)area dassification requirements let states plan for local land use. Each PSD classification d'rffers in the amount of development it will allow.Acceptable growth is estimated using computerized air dispersion modeling techniques to gauge the effects of current and potential pollution sources on surrounding areas. PSD regulations:allow for three area classifications: • Class I areas allow the smallest incremental growth and accommodate only a small degree of air quality deterioration; • Class II areas can accommodate normal, well-managed industrial growth; and • Class III areas allow the largest increments of growth and provide fora larger amount of development than either Class I or Class II areas. Congress has identified several mandatory Class I areas and allows state and tribal authorities to designate other Class I areas. In Montana,the following areas have been designated as Class I areas: • National Parks: Glacier and Yellowstone; • National Wilderness Areas: Anaconda-Pintler, Bob Marshall, Cabinet Mountains, Gates of the Mountains, Medicine Lake, Mission Mountains, Red Rock Lakes, Scapegoat, Se lway-Bitterroot, and UL Bend; and • Native American Reservations: Northern Cheyenne, Flathead, and Fort Peck. 1 t ' Iwo* f j Hi- 40 Clan 1A4r#Jwd Yama� , Areas designated as Class I.areas are those national parks greater than 6,000 acres, wilderness areas and national memorial parks greater than 5,000 acres, and all international parks in existence on August 7, 1977. States and Tribes may designate additional areas. .. rah ,.' � � �'� f � �•., ., � - rE� u wx p t 1 '244 lk 1 � � o 'a .• _ t•y '� r ow x` 0 Jsr Id_.r1 --�. y�• .. r NrgC-... i y..._. C 3,Q t ,� ... u J O 7 -0 � iffe ' NA p,rn. r rg 0 4ANIGMWRytwVE__ T7i.W Y ✓_. lx;t TRAIL RA, a � yA szw QQLL CODE a ....MUSNft4i LN-__..-s+---._._�..__—.�..� )bw"H MONTANA NATURAL HERITAGE PROGRAM MAP MONTANA Vatuml Heritage Animal Species of Concern Species List Last Updated 04/21/2014 Frograin 15 Species of Concern 1 Special Status Species Filtered by the following criteria: A program of the Montana State Library. QQLL=2704(based on mapped Species Occurrences) Natural Resource Information System operated by the University of Mordana. Species of Concern is Speias ;.. Filtered bythe} rfleria: QQIt-27D4(kr" .dM�'epapped SpedesfYaumrnms) " i ; " '. `. .;.. MAMMALS (MAMMALIA) 5 SPECIES FILTERED BY THE FOLLOWING CRITERIA: CynOfllys SCluritlas G4 S3 SENSITIVE SENSITIVE 1 15% 71% Grasslands IYdOVleianYS Squirrels Speeles Occurrences verified In these Counties:Big Horn,Blaine,Carbon,Carter,Cascade,Chouteau,Custer,Fallon,Fergus,Garfield, Golden Valley,Hill, Black-[ailed Prairie Dog Jefferson,Judith Basin,Lewis and Clark,Liberty,Mccone,Musselshell, Petroleum,Phillips,Powder River, Prairie, Richland,Rosebud,Stillwater, Sweet Grass,Toole, Treasure,Valley,Wheatland,Yellowstone GYIo gulo Mustelidae G4 S3 SENSITIVE SENSITIVE 2 0111 37% Boreal Forest and Alpine Wolverine Weasels I I I HabRnh Species Occurrences verified In these Counties:Beaverhead,Broadwater,Carbon,Cascade,Deer Lodge,Flathead,Gallatin,Glacier,Granite,Jefferson,Judith Basin,Lake,Lewis and Clark,Lincoln,Madison,Meagher,Mineral,Missoula,Park, Pondera,Powell,Ravalli,Sanders,Silver Bow,Stillwater,Sweet Grass,Teton, Wheatland Lasiums Clnereus Vespertilionidae GS S3 2 2% 100% Riparian and forest Hoary Bat Bats Species Occurrences verified In theme Counties:Beaverhead, Big Horn,Blaine, Broadwater,Carbon,Carter,Cascade,Chouteau,Custer,Daniels,Dawson, Deer Lodge,Fallon, Fergus,Flathead,Gallatin,Garfield,Glacier,Golden Valley,Granite,Hill,Jefferson,Judith Basin,Lake,Lewis and Clark,Liberty,Lincoln,Madison, Mccone,Meagher, Mineral,Missoula,Musselshell,Park,Petroleum, Phillips, Ponders,Powder River,Powell, Prairie,Ravalli,Richland,Roosevelt,Rosebud, Sanders, Sheridan,Silver Bow,Stillwater,Sweet Grass,Teton,Toole,Treasure,Valley, Wheatland,Wibaux,Yellowstone Myotis lucifugus Vespertilionidae G3 'S3 ' 3 3% 100% Generalist Little Brown Myotis Bats Species Occurrences verified In these Counties:Beaverhead,.Big Horn,Blaine,Broadwater,Carbon,Carter,Cascade,Chouteau,Custer,Daniels, Dawson, Deer Lodge,Fallon,Fergus,Flathead,Gallatin,Garfield,Glacier,Golden valley,Granite, Hill,Jefferson,Judith Basin,Lake,Leads and Clark,Lincoln, Madison,Mccone, Meagher,Mineral,Missoula,Musselshell,Park,Petroleum,Phillips, Pondera,Powder River,Powell,Prairie,Ravalli, Richland,Roosevelt, Rosebud,Sanders,Sheridan, Silver Bow,Stillwater,Sweet Grass,Teton,Toole,Treasure,Valley,Wheatland,Wibaux,Yellowstone Myotis thysanodes Vespertilionidae G4 S3 SENSITIVE 2 0011 64% Riparian and dry mixed Fringed Myotis Bab I I I I I conifer forests Species Occurrences verified in these Counties:Beaverhead,Big Horn,Blaine,Broadwateq Carbon,Carter,Cascade,Custer, Deer Lodge,Fergus,Flathead, Granite,Jefferson,Judith Basin,Lake,Lewis and Clark,Lincoln,Madison, Meagher, Mineral, Missoula, Powder River,Powell,Prairie,Ravalli, Rosebud,Sanders,Silver Bow,Teton FILTERED BY THE FOLLOWING CRITERIA: BIRDS (BASED ON MAPPED Ardea herodias Ardeidae G5 I S3 I I 1 1 3 1 3% 1 100% 1 Riparian forest Great Blue Heron Bitterns/Egrets/Herons Species Occurrences verified in these Counties:Beaverhead, Big Horn,Blaine,Broadwater,Carbon,Carter,Cascade,Chouteau,Custer,Dawson,Deer Lodge, /Night-Herons Fallon, Fergus, Flaimead,Gallatin,Garfield,Glacier,Golden Valley,Granite,Hill,Jefferson,Judith Basin, Lake,Lewis and Clark, Liberty,Lincoln,Madison,Mccone, Meagher,Mineral, Missoula, Musselshell, Park,Petroleum,Phillips,Pondera,Powder Riven Powell,Prairie,Ravalli,Richland, Roosevelt,Rosebud, Sanders,Sheridan, Silver Bow,Stillwater,Sweet Grass,Teton,Treasure,Valley,Wheatland,Wibaux,Yellowstone State Rank Reason:Small breeding population size,evidence of recent declines,and declining regeneration of riparian cottonwood forests due to altered hydrology and grazing. Catharvs Turd'Idae G5 >S38 2 6% 100% Riparian forest fuseeseens Thrushes Species Occurrences verified in these Counties:Beaverhead,Big Horn,Blaine,Broadwater,Carbon,Cascade,Chouteau,Custer,Deer Lodge,Fergus,Flathead, Veery Gallatin,Glacier,Granite,Jefferson,Lake,Lewis and Clark,Liberty,Lincoln,Madison,Mccone,Meagher,Mineral,Missoula,Musselshell,Park,Petroleum,Phillips, Pondera,Powder River,Powell,Ravalli, Richland, Roosevelt,Rosebud,Sanders,Silver Bow,Stillwater,Sweet Grass,Teton,Wheatland,Yellowstone CharadrlUS Charadriidae G3 S28 SENSITIVE 1 20% 73% Grasslands montanus Plovers Species Occurrences verified In these Counties:Blaine,Broadwater, Carbon,Fergus,Garfield,Golden Valley,Jefferson, Madison, Musselshell,Petroleum, Mountain Plover Phillips,Rosebud,Teton,Toole,Treasure,Valley,Wheatland,Yellowstone COCCothraustas Fringillidae GS. I S3 I I 1 1 3 3% 100% Conifer forest vespertinus Finches Species Occurrences verified In these Counties:Beaverhead, Broadwater,Carter,Cascade,Chouteau;Fergus,Flathead,Gallatin,Glacier,Golden Valley, Evening Grosbeak Granite,Jefferson,Judith Basin,Lake,Lewis and Clark,Lincoln,Madison,Meagher,Mineral,Missoula,Musselshell,Park,Pondera,Powder River,Powell,Ravalli, Sanders,Silver Bow,Stillwater,Sweet Grass,Teton,Wheatland State Rank Reason:Populabons in Montana and across North America have experienced rangewide declines,although the causes of these declines are unclear (8onter and Harvey 2008). Haemorhous Fringillidae GS I S3 3 11% 62% Drier conifer forest eassinii Finches Species Occurrences verified in these Counties:Beaverhead, Big Horn,Broadwater,Carbon,Cascade,Chouteau,Custer,Deer Lodge, Fergus,Flathead, Cassm's Finch Gallatin,Glacier,Golden Valley,Gran Te,Jefferson,Judith Basin,Lake, Lewis and Clark, Lincoln,Madison,Meagher, Mineral, Missoula,Musselshell,Park, Petroleum, Phillips, Powder River, Powell, Ravalii, Rosebud,Sanders,Silver Bow,Stillwater, Sweet Grass,Teton,Wheatland,Yellowstone Nueifraga Cotvidae G5 S3 3 9% 84% Conifer forest Columbiana - lays/Crows/Magpies Species Occurrences verified In these Counties:Beaverhead,Big Horn,Blaine,Broadwater,Carbon,Carter,Cascade,Chouteau,Deer Lodge,Fergus,Flathead, Clark's Nutcracker Gallatin,Glacier,Golden Valley,Granite,Jefferson,Judith Basin,Lake,Lewis and Clark,Liberty,Lincoln,Madison,Meagher, Mineral,Missoula,Musselshell,Park, Petroleum,Phillips,Pondera,Powder River,Powell,Ravalli,Sanders,Silver Bow,Stillwater,Sweet Grass,Teton,Toole,Wheatland Numenius Scolopacidae GS I S3B I I I SENSITIVE 1 1 1 19% 1 100% Grasslands americanus Sandpipers Species Occurrences verified In these Counties:Beaverhead,Big Horn, Blaine, Broadwater,Carbon,Carter,Cascade,Chouteau,Custer,Daniels, Dawson, Lang-billed Curlew Deer Lodge, Fallon,Fergus,Flathead,Gallatin,Glacier,Garden Valley,Granite, Hill,Jefferson,Judith Basin,Lake,Lewis and Clark,Liberty, Madison, Mccone, Meagher, Missoula,Musselshell, Petroleum,Phillips, Pondera,Powder River,Powell,Prairie,Ravalli,Richland,Roosevelt,Rosebud,Sanders,Sheridan,Stillwater,Sweet Grass, Teton,Toole,Treasure,Valley,Wheatland,Wibaux,Yellowstone Spizelia brevveri Emberizidae G5 I 5311 I I I SENSITIVE 2 12% 100% Sagebrush. Brewer's Sparrow Sparrows Species Occurrences verified In these Counties:Beaverhead,Big Horn, Blaine, Broadwater,Carbon,Carter,Chouteau,Custer,Dawson,Deer Lodge,Fallon, Fergus,Flathead,Gallatin,Garfield,Glacier,Golden Valley,Granite,Hill,Jefferson,Lake,Lewis and Clark,Liberty,Lincoln,Madison,Mccone,Meagher,Missoula, Musselshell,Park,Petroleum,Phillips,Pondera,Powder River,Powell,Prairie,Ravalli,Richland,Roosevelt,Rosebud,Sanders,Sheridan,Silver Bow,Stillwater,Sweet Grass,Teton,Toole,Treasure,Valley,Wheatland,Wibaux,Yellowstone State Rank Reason:Species faces threats from loss of sagebrush habitats it is dependent on as a result of habitat conversion for agriculture and increased frequency,of fire as a result of weed encroachment and drought. !ill 16111 liplat ill ii in s ' s Oneorhynchus Salmonidae G4T3 52 SENSITIVE SENSITIVE 1 34% Mountain streams, clarkii lev isi Trout rivers,lakes Westslope Cutthroat Species Occurrences verified In these Counties:Beaverhead, Broadwater,Cascade,Chouteau, Deer Lodge,Fergus, Flathead, Gallatin,Glacier,Granite, Trout Jefferson,Judith Basin, Lake, Lewis and Clark,Lincoln, Madison, Meagher,Mineral,Missoula, Park, Pondera, Powell, Ravalli,Sanders,Silver Bow,Teton,Wheatland FILTERED BY THE FOLLOWING CRITERIA: .. k Leucomhinia Libellulidae G5 et io% 36% Forested wetlands borealis Skimmer Dragonflies Species Occurrences verified In these Counties:Deer Lodge,3efferson,Lewis and Clark,Powe41,SIWer Bow Boreal Whiteface LiWcn for dM on this wsas m: Mx Prinel wears d Cacao Re ., "an'a Nat Heritage Pawn and""hsh,W1,19.and Perks. RcU a l U29'211S,from ktn'.l/rrtkm.ortY:�(]fCOrcaN?Paf§a � ° �:�® z a 4" Photo i Proposed building loca looking West Photo z Proposed sewer e_e_ awCentennial Ave. Photo 3: Proposed building location looking South Photo 4:Proposed building location looking East Photo 5: Looking east along W Centennial Ave.from NW corner of County property Photo 6: Proposed building location looking Southeast ro x m� I RAW. i RR:: SY=DESIGNATIONS t ROUE SURFACE.TYFE PaM Aare •64E • � Ureih[e/ I ROUTE SWNWO if . ® awsVe Mpnny � V3 R9xaN xb�xaiaRaa � `r�FRar PROJECT LOCATION mum<nAa>Es �asrax 1 VSM VnoxSa:o. —_..— ..®—. OTHER SY.%MLS cx- Zara span -.. xwen �la iY106F � Vlar neava.uamr Qaf.ICGtIN 31 35 _ a S PAYED 9411E j ? STAII W S81.YIAlG .f�' " � e . 0lSAYS]@ikKlYAE8iSA181[S RQADLR'E919b'.ADB WTMG![CSM!, cDa�ex�9��co�mo R1W Rlfr/7f 11SDW ttyeW 1,a•]W i12tlW 2701 Prospect Avenue PO Box 201001 AM W Montana Department of Transportation Helena,MT59620-1001 Transportation (406)4447228 MDT-ENV-006 11113 Environmental Checklist Fax J406)4447245 TTY:(406)4447696 Page 1 of 2 www mdt m1mv Control Number/UPN Project Identification Number Name/Location Description Route/Corridor Federal Funds Involved? a Date Choose t pe of Environmental Checklist: EncroachmenUOccupancy(including Utility) Highway or Route: Milepost(s): Name: Title W Centennial Ave.(CO22206) 600'W of P-69 lJohn Shephard lFacilities Manager Physical Address: City: Company/Utility: 201 W.Centennial Ave. Boulder Jefferson County Legal Description: County: Mailing Address: Phone: I Jefferson JPO Box H 114062254065 Township: Range: Section(s): City: State: Zip: Business Phone: 16 N 114 W 1129 Boulder MT 59632 4062254065 *16n Impact Questions Comment,Explanation,and/or Actionsthat qualify For Categorical Exclusion under MEPA and/or NEPA(See ARM 18.2161 and 23 CFR 771.117) Information source iae.d.upp.naw (See ARM 18.2161 and 23.CFR 771.117) mr.rm.n`a," iury0 1 Will the proposed action impact any known historical or archaeological site(s)? (".Yes G.No 2...Will the proposed action impact any publicly owned parldand(s),recreation area(s),wildlife or waterfowl (^..Yes GNo refuge(s)? 3 Will the proposed action impact prime farmlands?(If yes,attach a completed Farmland Conversion Impact Rating r Yes G No Ad-1006.) a.Will the proposed action haw an impact on the human environment that may result from relocations of >6 Yes No persons or businesses,changes in traffic patterns,changes In grade,or other types of changes? b.Has the proposed action received any preliminary or final approval from the local land use authority? G.Yes C No 5 For the proposed action,is there documented controversy on environmental grounds?(For example,has the Yes G No applicant received a letter of petition from an environmental organization?) 6 Will the proposed action require work in,across or adjacent to a listed or proposed Wild or Scenic River? ('.Yes G,No 7 Will the proposed action require work In a Class I Air Shed or nonattainment area? C Yes G No 8 Will the proposed action Impact air quality or Increase noise,even temporarily? G Yes ("No 9 a.Is the proposed project a MS4 Area?(Billings,Bozeman,Butte,Helena,Great Falls,Kalispell,and Missoula) ("'.Yes G No b.Will the proposed action have potential to affect water quality,wetlands,streams or other water bodies?RYES, f- Yes GNo an environment-related permit or authorization may be required. 10 Are solid or hazardous wastes or petroleum products likely to be encountered?(For example,project occurs in or r Yes G No adjacent to 5uperfund sites,known spill areas,understorage tanks,or abandoned mines.) 11 a. Are there any listed or candidate threatened or endangered species,or critical habitat in the vicinity of the (: Yes C':No proposed action? b.Will the proposed action adversely affect listed or candidate threatened or endangered species,or adversely (^yes (,p No modify critical:habitat? 12 Will the proposed action require an environmental-related permit or authorization? (` Yes G.No If the answer is"yes,"please list the specific permits or authorizations. 13 a. Is the proposed action on or within approximately 1 mile of an Indian Reservation? r".Yes f• No b.If'Yes,will a Tribal Water Permit be required? (—Yes rNo GN/A 14 Will the proposed action result in Increased traffic volumes,increased wait or delays on state highways,or have (: Yes (`No adwrW impaction other forms of transportation trail.transit or air movementsl? Is the proposed action part of a project that may require other governmental permits,licenses or easements? if GYes CNo 15 "Yes",describe the full extent of the project and any other permits,licenses or easements that may be necessary for the applicant to acquire. 2701 Prospect Avenue PO Box 201001 AM W Montana Department of Transportation Helena,MT59620-1001 Phone:(406)444.7228 MDT-ENV-006 11/13 Environmental Checklist Fax(406)444-7245 TTY:(406)4447696 Page 2 of 2 www mdt mt aov 16..Attach a brief description of the work to be performed,Including any subsurface work. ® -Description Attached 17 Attach representative photos of the site(s)where the proposed action would be implemented. Photos are ® Photos Attached to include any structures,streams,irrigation canals,and/or potential wetlands in the project area. 18 Attach map(s)showing the location(s)of the proposed action(s);Section,Township,Range;highway or ® Maps Attached route number and approximate route post(s). Checklistpreparer" Title: Date Ryan Holm Project Engineer May 5,2015 Signature Reviewed for completeness by: MDT (strict Representative Title Date Checklist Approved by: Environmental Services Bureau Title Date (When any of the Items 1 through 15 are checked"Yes") Transportation Planning Title Date (When any of the items 14 or 15 are checked'Yes") Checklist Conditions and Required Approvals A. The applicant is not authorized to proceed with the proposed work until the checklist has been reviewed and approved,as necessary,and any requested conditions of approval have been incorporated. B. Complete the checklist items 1 through 15,indicating"Yes"or"No"for each item. Include comments,explanations,information sources, and a description of the magnitude/importance of potential impacts in the right hand column. Attach additional and supporting information as needed. Ensure that information required for items 16,17,and 18,is attached. The checklist preparer, by signing,certifies the accuracy of the information provided. C. If"Yes"is indicated on any of the items,the Applicant must explain the Impacts as applicable. Appropriate mitigation measures that will be taken to avoid, minimize, and/or mitigate adverse impacts must also be described. Any proposed mitigation measures will become a condition of approval. Use attachments if necessary. If the applicant checks"No"and the District concludes there may in fact be potential impacts,the Environmental Checklist must be forwarded to Environmental Services Bureau for review and approval. D. If"Yes" is indicated in item 11 a. (threatened or endangered species), the Applicant should provide Information naming the particular species and the expected location,distribution and habitat use in the proposed action area,i.e.within the immediate area of the proposed action;or,in the general area on occasion(seasonally passes through)but does not nest,den or occupy the area for more than a few days. E. If the applicant checks"Yes"for any item,the approach permit, occupancy agreement or permit, along with the checklist and supporting information, including the Applicant's mitigation proposal, documentation, evaluation and/or permits must be submitted to MDT Environmental Services Bureau. Electronic format Is preferred. F. When the applicant checks Wes"to any item,the Applicant cannot be authorized to proceed with the proposed work until the MDT Environmental Services Bureau and/or Transportation Planning, as appropriate, reviews the information and signs the checklist. G. Applicant must obtain all necessary permits or authorizations from other entities with jurisdiction prior to beginning the proposed action or activity.The Applicant is solely responsible for any environmental impacts Incurred as a result of the project; obtaining any necessary environmental permits,notifications,and/or clearances;and ensuring compliance with environmental laws and regulations. (, CONTROL POINT COORDINATE TABLE iqe la x auc /yyM pp EABIINO EIEYATRMI OESLPoP/NW ' u[v. easy 1 NpRll ® MWJL IT- ' Q �wCIVIL DEMOLITION PLAN KEY ''' b TTT NOTES r - ` o�ww mxc'�OEmirnoxramxrouxw.MOrea "Ty:"may' o FAmwm6 QETAT aTOW U D.Mrmm W CENTENNIAL"E. erctt.mrwaerrrswxuocw�xnre.,unre. TDM.aw.MDaecru M �elrenon coumyc - 6RewNelMmx uu � 1MiuDMML VOioREwH.mortttuwn a.nn v w lT^1� wa[x aa[ U! � MrtaFM awrtcwaRmuvwrtmattwcnw .wt wn ewxo:n Iml 1311 nmec rnww u.x� � roeDMrt xo __ MwnxaCNna/.¢[nmeE a m [uemro pmtw+ra N'fESS .wxe.mqYa -O � i MORCnDTMNg1YVlRW6AFIIwneM1 -,. _ n' . 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