HomeMy WebLinkAboutC7. MDT Encrouchment
Commission Memorandum REPORT TO: Honorable Mayor and City Commission FROM: David Fine, Economic Development Specialist SUBJECT: Encroachment Permits from the Montana Department of Transportation (MDT) for the Downtown – North 7th Conduit Project
MEETING DATE: June 6, 2016
AGENDA ITEM TYPE: Consent RECOMMENDATION: Authorize the City Manager to sign MDT Encroachment Permits for the Downtown – North 7th Conduit Project. BACKGROUND: Main Street, North 7th Avenue, and Rouse Avenue are routes whose rights of way are controlled and managed by the Montana Department of Transportation (MDT). The City of Bozeman is installing conduit to facilitate the installation of telecommunications facilities by the private sector. The two encroachment permit applications presented here are located at the following locations:
• Intersection of Oak St., and N. 7th Ave.
• Mid-block crossing between N. Wallace Ave. and N. Broadway Ave.
o This crossing is contingent on an easement from the property owner, 777 Building LLC due to MDT regulations about parallel encroachments in the right of way. Negotiations are ongoing and have thus far been productive. Encroachment permits are required to place City-owned conduit in right of way controlled by MDT. The City Commission recently approved a Memorandum of Agreement with MDT which set forth the respective responsibilities and duties of the City and MDT when City conduit is installed in MDT controlled right of way and
310
use of the conduit is subsequently licensed to the private sector. The approval of this MOA by the parties was a prerequisite for the subsequent approval of encroachment permits that will allow the physical installation of City conduit in MDT controlled right of way.
FISCAL EFFECTS: None at this time.
ATTACHMENT: Encroachment Permits with Montana Department of Transportation:
• Intersection of Oak St., and N. 7th Ave.
• Mid-block crossing between N. Wallace Ave. and N. Broadway Ave.
311
MDT-MAI-007 07/14
Page 1 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
To be filled in by Department of Transportation Personnel
Agreement Number: Project Number: Project Name:
Corridor:
County:
Maintenance Section:Sign Route:
ID Number:
Roadbed:Milepost:
Montana Department of
Transportation Title Signature Date
Subject to the terms and conditions shown on Page 2 hereof; this permit is hereby approved and granted. The “Permittee” agrees to the terms of this permit.
APPLICANT (PROPERTY OWNER)
NATURE OF PERMIT APPLICATION:
(Give sufficient detail to permit thorough understanding and submit blueprints or sketches in triplicate.)
*If work involves Environmental-Related cleanup or monitoring, also complete Section 7.
Township Section Range /Corridor Sign
Route
Mile Post
Name Phone\Fax Number
Address E-mail
City State Zip Code
If a Corporation, give State of Incorporation and names of President and Secretary
Highway survey stations, milepost, distances to centerline, and distance from right-of-way line near which
installations or structures will be installed:
For how long a period is the permit
desired?:Are there environmental actions involving hazardous waste sites? (Superfund, Spills,
Underground Storage Tanks, Old Mines, etc.) If Yes you will need to fill out additional
environment questions.
Yes (Complete Page
3) No
An environmental checklist must be filled out, signed and attached in order for this application to be considered
complete.
Company or Corporation Title DateSignature
Print Form
MT
Link to Environmental Checklist
312
MDT-MAI-007 07/14
Page 2 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
(INSTRUCTIONS CONCERNING USE OF THIS FORM)
Applicant will complete this form along with plans, sketches and an environmental checklist and send to the appropriate District Maintenance Chief for review and
approval.
If the proposed installation will result in significant, permanent or long term impacts to the transportation network in terms of substantial increase traffic volumes,
weight or delays to traffic on state roadways, such as major mines greater than five acres, a railroad at -grade crossing, railroad under or overpass, or strip
mines, or if the proposed action has permanent impacts to other forms of transportation (rail, transit, or air movement), the encroachment permit must be
submitted to the transportation planning division for review prior to issuance of this permit.
Subject to the following terms and conditions, the permit applied for upon the reverse side hereof, is hereby granted:TERM. This permit shall be
in full force and effect from the date hereof until revoked as herein provided.REVOCATION. This permit may be revoked
by State upon giving 45 days notice to Permittee by ordinary mail, sent to the address shown herein. However, the State
may revoke this permit without notice if Permittee violates any of its conditions or terms.COMMENCEMENT OF WORK.
No work shall be commenced until Permittee notifies the Maintenance Chief shown in application the date the Permittee
proposes to commence work.CHANGES IN HIGHWAY. If State highway changes necessitate changes in structures or
installations installed under this permit, Permittee will make necessary changes without expense to State.STATE SAVED
HARMLESS FROM CLAIMS. As a consideration of being issued this permit, the Permittee, 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 Permittee, 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.PROTECTION OF TRAFFIC. The Permittee shall protect the work
area with traffic control devices that comply with the Manual of Uniform Traffic Control Devices. The Permittee may be
required to submit a traffic control plan to the Maintenance Chief for approval prior to starting work. During work, the
Maintenance Chief or designee may require the Permittee to use additional traffic control devices to protect traffic or the
work area. No road closure shall occur without prior approval from the District Engineer.HIGHWAY AND DRAINAGE. If
the work done under this permit interferes in any way with the drainage of the State highway affected. Permittee shall, at
the Permittee's expense, make such provisions as the State may direct to remedy the interference.RUBBISH AND
DEBRIS. Upon completion of work contemplated under this permit, all rubbish and debris shall be immediately removed
and the roadway and roadside left in a neat and presentable condition satisfactory to the State.INSPECTION. The
installation authorized by this permit shall be in compliance with the attached plan and the conditions of this permit. The
Permittee may be required to remove or revise the installation, at sole expense of Permittee, if the installation does not
conform with the requirements of this permit or the attached plan.STATE'S RIGHT NOT TO BE INTERFERED WITH. All
changes, reconstruction or relocation shall be done by Permittee so as to cause the least interference with any of the
State's work, and the State shall not be liable for any damage to the Permittee by reason of any such work by the State,
its agents, contractors or representatives, or by the exercise of any rights by the State upon the highways by the
installations or structures placed under this permit.REMOVAL OF INSTALLATIONS OR STRUCTURES. Unless waived
by the State, upon termination of this permit, the Permittee shall remove the installations or structures installed under this
permit 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 Permittee has no control,
excepted.MAINTENANCE AT EXPENSE OF PERMITTEE. Permittee shall maintain, at its sole expense, the installations
and structures for which this permit is granted, in a condition satisfactory to the State.STATE NOT LIABLE FOR
DAMAGE TO INSTALLATIONS. In accepting this permit, the Permittee agrees that any damage or injury done to said
installations or structures by a contractor working for the State, or by any State employee engaged in construction,
alteration, repair, maintenance or improvement of the State highway, shall be at the sole expense of the
Permittee.STATE TO BE REIMBURSED FOR REPAIRING ROADWAY. Upon being billed, therefore, Permittee 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 permit.The Permittee shall not discharge
20.OTHER CONDIDTIONS AND/OR REMARKS:
21.See attached addendum
313
MDT-MAI-007 07/14
Page 3 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
314
MDT-MAI-007 07/14
Page 4 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
Additional Environmental Questions Pertaining to Environmental actions involving hazardous waste sites
(Superfund, Spills, Underground Storage Tanks, Old Mines, etc.)
Name of Facility:
Address: City State Zip Code
Facility ID:
MDEQ identification
number
Leaking underground storage tank
site?Petro Fund Eligible?
identification number and/or site
name
Remediation Response Sites (State Superfund
Site)?
identification number and/or site
name
Federal Superfund
Site?
Is Mine Active or
Abandoned?
Spill?
Mine Site ID#Mine Description or
Name
Spill Site Spill Description
Other Environmental Action
Check Boxes that are applicable below and provide subsequent details
Yes
No
For each well installed in MDT R/W, provide GPS coordinates in state plane coordinates (preferred) or well survey
information in another format (continue on another sheet if necessary).
NOTE: Each well request needs to be submitted on a separate application form.
Well Designation Easting Northing
Traffic Control Plan
Attached?
MT
Add Well
X
315
MDT-ENV-006 11/13
Page 1 of 3
Montana Department of Transportation
Environmental Checklist
2701 Prospect Avenue
PO Box 201001
Helena, MT 59620-1001
Phone: (406) 444-7228
Fax (406) 444-7245
TTY: (406) 444-7696
www.mdt.mt.gov
Control Number/
UPN
Project Identification
Number Name/ Location Description Route/Corridor Federal Funds Involved?
(↑For MDT Use Only↑)
Choose type of Environmental Checklist:Date
Location
Highway or Route: Milepost(s):
Physical Address: City:
Legal Description:County:
Township: Range: Section(s):
Applicant Information:
Name:Title
Company/Utility:
Mailing Address:Phone:
City:State: Zip: Business Phone:
Impact Questions
Actions that qualify for Categorical Exclusion under MEPA and/or NEPA (See ARM 18.2.261 and 23 CFR 771.117)
(See ARM 18.2.261 and 23 CFR 771.117)
Comment, Explanation, and/or
Information Source (Attach
supporting information, as necessary.)
1 Will the proposed action impact any known historical or archaeological site(s)?Yes N
o
2 Will the proposed action impact any publicly owned parkland(s), recreation area(s), wildlife or waterfowl
refuge(s)?
Yes N
o
3 Will the proposed action impact prime farmlands? (If yes, attach a completed Farmland Conversion Impact
Rating Ad-1006.)
Yes N
o
4 a. Will the proposed action have an impact on the human environment that may result from relocations of
persons or businesses, changes in traffic patterns, changes in grade, or other types of changes?Yes N
o
b. Has the proposed action received any preliminary or final approval from the local land use authority?Yes N
o
5 For the proposed action, is there documented controversy on environmental grounds? (For example, has
the applicant received a letter of petition from an environmental organization?)
Yes N
o
6 Will the proposed action require work in, across or adjacent to a listed or proposed Wild or Scenic River?Yes N
o
7 Will the proposed action require work in a Class I Air Shed or nonattainment area?Yes N
o
8 Will the proposed action impact air quality or increase noise, even temporarily?Yes N
o
9 a. Is the proposed project a MS4 Area? (Billings, Bozeman, Butte, Helena, Great Falls, Kalispell, and
Missoula)Yes N
o
b. Will the proposed action have potential to affect water quality, wetlands, streams or other water bodies?
If YES, an environment-related permit or authorization may be required.Yes N
o
10 Are solid or hazardous wastes or petroleum products likely to be encountered? (For example, project
occurs in or adjacent to Superfund sites, known spill areas, understorage tanks, or abandoned mines.)
Yes N
o
11 a. Are there any listed or candidate threatened or endangered species, or critical habitat in the vicinity of
the proposed action?Yes N
o
b. Will the proposed action adversely affect listed or candidate threatened or endangered species, or
adversely modify critical habitat?Yes N
o
12 Will the proposed action require an environmental-related permit or authorization?
If the answer is "yes," please list the specific permits or authorizations.Yes N
o
13 a. Is the proposed action on or within approximately 1 mile of an Indian Reservation?Yes N
o
b. If “Yes”, will a Tribal Water Permit be required?Yes No N/A
14 Will the proposed action result in increased traffic volumes, increased wait or delays on state highways, or
have adverse impacts on other forms of transportation (rail, transit or air movements)?
Yes N
o
15
Is the proposed action part of a project that may require other governmental permits, licenses or
easements? If “Yes”, describe the full extent of the project and any other permits, licenses or easements
that may be necessary for the applicant to acquire.
Yes N
o
MDT Environmental Checklist Help Guide
(Click button or go to www.mdt.mt.gov/other/environmental/external/forms/ENVIRONMENTAL-CHECKLIST-HELPSHEET.PDF)
316
317
MDT-ENV-006 11/13
Page 3 of 3
Montana Department of Transportation
Environmental Checklist
2701 Prospect Avenue
PO Box 201001
Helena, MT 59620-1001
Phone: (406) 444-7228
Fax (406) 444-7245
TTY: (406) 444-7696
www.mdt.mt.gov
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.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.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. 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. 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.When the applicant checks “Yes” 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.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.
Checklist Conditions and Required Approvals
318
319
320
321
MDT-MAI-007 07/14
Page 1 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
To be filled in by Department of Transportation Personnel
Agreement Number: Project Number: Project Name:
Corridor:
County:
Maintenance Section:Sign Route:
ID Number:
Roadbed:Milepost:
Montana Department of
Transportation Title Signature Date
Subject to the terms and conditions shown on Page 2 hereof; this permit is hereby approved and granted. The “Permittee” agrees to the terms of this permit.
APPLICANT (PROPERTY OWNER)
NATURE OF PERMIT APPLICATION:
(Give sufficient detail to permit thorough understanding and submit blueprints or sketches in triplicate.)
*If work involves Environmental-Related cleanup or monitoring, also complete Section 7.
Township Section Range /Corridor Sign
Route
Mile Post
Name Phone\Fax Number
Address E-mail
City State Zip Code
If a Corporation, give State of Incorporation and names of President and Secretary
Highway survey stations, milepost, distances to centerline, and distance from right-of-way line near which
installations or structures will be installed:
For how long a period is the permit
desired?:Are there environmental actions involving hazardous waste sites? (Superfund, Spills,
Underground Storage Tanks, Old Mines, etc.) If Yes you will need to fill out additional
environment questions.
Yes (Complete Page
3) No
An environmental checklist must be filled out, signed and attached in order for this application to be considered
complete.
Company or Corporation Title DateSignature
Print Form
MT
Link to Environmental Checklist
322
MDT-MAI-007 07/14
Page 2 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
(INSTRUCTIONS CONCERNING USE OF THIS FORM)
Applicant will complete this form along with plans, sketches and an environmental checklist and send to the appropriate District Maintenance Chief for review and
approval.
If the proposed installation will result in significant, permanent or long term impacts to the transportation network in terms of substantial increase traffic volumes,
weight or delays to traffic on state roadways, such as major mines greater than five acres, a railroad at -grade crossing, railroad under or overpass, or strip
mines, or if the proposed action has permanent impacts to other forms of transportation (rail, transit, or air movement), the encroachment permit must be
submitted to the transportation planning division for review prior to issuance of this permit.
Subject to the following terms and conditions, the permit applied for upon the reverse side hereof, is hereby granted:TERM. This permit shall be
in full force and effect from the date hereof until revoked as herein provided.REVOCATION. This permit may be revoked
by State upon giving 45 days notice to Permittee by ordinary mail, sent to the address shown herein. However, the State
may revoke this permit without notice if Permittee violates any of its conditions or terms.COMMENCEMENT OF WORK.
No work shall be commenced until Permittee notifies the Maintenance Chief shown in application the date the Permittee
proposes to commence work.CHANGES IN HIGHWAY. If State highway changes necessitate changes in structures or
installations installed under this permit, Permittee will make necessary changes without expense to State.STATE SAVED
HARMLESS FROM CLAIMS. As a consideration of being issued this permit, the Permittee, 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 Permittee, 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.PROTECTION OF TRAFFIC. The Permittee shall protect the work
area with traffic control devices that comply with the Manual of Uniform Traffic Control Devices. The Permittee may be
required to submit a traffic control plan to the Maintenance Chief for approval prior to starting work. During work, the
Maintenance Chief or designee may require the Permittee to use additional traffic control devices to protect traffic or the
work area. No road closure shall occur without prior approval from the District Engineer.HIGHWAY AND DRAINAGE. If
the work done under this permit interferes in any way with the drainage of the State highway affected. Permittee shall, at
the Permittee's expense, make such provisions as the State may direct to remedy the interference.RUBBISH AND
DEBRIS. Upon completion of work contemplated under this permit, all rubbish and debris shall be immediately removed
and the roadway and roadside left in a neat and presentable condition satisfactory to the State.INSPECTION. The
installation authorized by this permit shall be in compliance with the attached plan and the conditions of this permit. The
Permittee may be required to remove or revise the installation, at sole expense of Permittee, if the installation does not
conform with the requirements of this permit or the attached plan.STATE'S RIGHT NOT TO BE INTERFERED WITH. All
changes, reconstruction or relocation shall be done by Permittee so as to cause the least interference with any of the
State's work, and the State shall not be liable for any damage to the Permittee by reason of any such work by the State,
its agents, contractors or representatives, or by the exercise of any rights by the State upon the highways by the
installations or structures placed under this permit.REMOVAL OF INSTALLATIONS OR STRUCTURES. Unless waived
by the State, upon termination of this permit, the Permittee shall remove the installations or structures installed under this
permit 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 Permittee has no control,
excepted.MAINTENANCE AT EXPENSE OF PERMITTEE. Permittee shall maintain, at its sole expense, the installations
and structures for which this permit is granted, in a condition satisfactory to the State.STATE NOT LIABLE FOR
DAMAGE TO INSTALLATIONS. In accepting this permit, the Permittee agrees that any damage or injury done to said
installations or structures by a contractor working for the State, or by any State employee engaged in construction,
alteration, repair, maintenance or improvement of the State highway, shall be at the sole expense of the
Permittee.STATE TO BE REIMBURSED FOR REPAIRING ROADWAY. Upon being billed, therefore, Permittee 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 permit.The Permittee shall not discharge
20.OTHER CONDIDTIONS AND/OR REMARKS:
21.See attached addendum
323
MDT-MAI-007 07/14
Page 3 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
324
MDT-MAI-007 07/14
Page 4 of 4
Montana Department of Transportation
Encroachment Application
2701 Prospect Avenue
PO Box 5895
Helena, MT 59604-5895
Phone: (406) 444-7220
Fax (406) 444-7684
TTY: (406) 444-7696
www.mdt.mt.gov
Additional Environmental Questions Pertaining to Environmental actions involving hazardous waste sites
(Superfund, Spills, Underground Storage Tanks, Old Mines, etc.)
Name of Facility:
Address: City State Zip Code
Facility ID:
MDEQ identification
number
Leaking underground storage tank
site?Petro Fund Eligible?
identification number and/or site
name
Remediation Response Sites (State Superfund
Site)?
identification number and/or site
name
Federal Superfund
Site?
Is Mine Active or
Abandoned?
Spill?
Mine Site ID#Mine Description or
Name
Spill Site Spill Description
Other Environmental Action
Check Boxes that are applicable below and provide subsequent details
Yes
No
For each well installed in MDT R/W, provide GPS coordinates in state plane coordinates (preferred) or well survey
information in another format (continue on another sheet if necessary).
NOTE: Each well request needs to be submitted on a separate application form.
Well Designation Easting Northing
Traffic Control Plan
Attached?
MT
Add Well
X
325
MDT-ENV-006 11/13
Page 1 of 3
Montana Department of Transportation
Environmental Checklist
2701 Prospect Avenue
PO Box 201001
Helena, MT 59620-1001
Phone: (406) 444-7228
Fax (406) 444-7245
TTY: (406) 444-7696
www.mdt.mt.gov
Control Number/
UPN
Project Identification
Number Name/ Location Description Route/Corridor Federal Funds Involved?
(↑For MDT Use Only↑)
Choose type of Environmental Checklist:Date
Location
Highway or Route: Milepost(s):
Physical Address: City:
Legal Description:County:
Township: Range: Section(s):
Applicant Information:
Name:Title
Company/Utility:
Mailing Address:Phone:
City:State: Zip: Business Phone:
Impact Questions
Actions that qualify for Categorical Exclusion under MEPA and/or NEPA (See ARM 18.2.261 and 23 CFR 771.117)
(See ARM 18.2.261 and 23 CFR 771.117)
Comment, Explanation, and/or
Information Source (Attach
supporting information, as necessary.)
1 Will the proposed action impact any known historical or archaeological site(s)?Yes N
o
2 Will the proposed action impact any publicly owned parkland(s), recreation area(s), wildlife or waterfowl
refuge(s)?
Yes N
o
3 Will the proposed action impact prime farmlands? (If yes, attach a completed Farmland Conversion Impact
Rating Ad-1006.)
Yes N
o
4 a. Will the proposed action have an impact on the human environment that may result from relocations of
persons or businesses, changes in traffic patterns, changes in grade, or other types of changes?Yes N
o
b. Has the proposed action received any preliminary or final approval from the local land use authority?Yes N
o
5 For the proposed action, is there documented controversy on environmental grounds? (For example, has
the applicant received a letter of petition from an environmental organization?)
Yes N
o
6 Will the proposed action require work in, across or adjacent to a listed or proposed Wild or Scenic River?Yes N
o
7 Will the proposed action require work in a Class I Air Shed or nonattainment area?Yes N
o
8 Will the proposed action impact air quality or increase noise, even temporarily?Yes N
o
9 a. Is the proposed project a MS4 Area? (Billings, Bozeman, Butte, Helena, Great Falls, Kalispell, and
Missoula)Yes N
o
b. Will the proposed action have potential to affect water quality, wetlands, streams or other water bodies?
If YES, an environment-related permit or authorization may be required.Yes N
o
10 Are solid or hazardous wastes or petroleum products likely to be encountered? (For example, project
occurs in or adjacent to Superfund sites, known spill areas, understorage tanks, or abandoned mines.)
Yes N
o
11 a. Are there any listed or candidate threatened or endangered species, or critical habitat in the vicinity of
the proposed action?Yes N
o
b. Will the proposed action adversely affect listed or candidate threatened or endangered species, or
adversely modify critical habitat?Yes N
o
12 Will the proposed action require an environmental-related permit or authorization?
If the answer is "yes," please list the specific permits or authorizations.Yes N
o
13 a. Is the proposed action on or within approximately 1 mile of an Indian Reservation?Yes N
o
b. If “Yes”, will a Tribal Water Permit be required?Yes No N/A
14 Will the proposed action result in increased traffic volumes, increased wait or delays on state highways, or
have adverse impacts on other forms of transportation (rail, transit or air movements)?
Yes N
o
15
Is the proposed action part of a project that may require other governmental permits, licenses or
easements? If “Yes”, describe the full extent of the project and any other permits, licenses or easements
that may be necessary for the applicant to acquire.
Yes N
o
MDT Environmental Checklist Help Guide
(Click button or go to www.mdt.mt.gov/other/environmental/external/forms/ENVIRONMENTAL-CHECKLIST-HELPSHEET.PDF)
326
327
MDT-ENV-006 11/13
Page 3 of 3
Montana Department of Transportation
Environmental Checklist
2701 Prospect Avenue
PO Box 201001
Helena, MT 59620-1001
Phone: (406) 444-7228
Fax (406) 444-7245
TTY: (406) 444-7696
www.mdt.mt.gov
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.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.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. 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. 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.When the applicant checks “Yes” 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.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.
Checklist Conditions and Required Approvals
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ATTACHMENT 1
CITY OF BOZEMAN
UTILITY LOCATIONS
334
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337