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NETL F 451.1 -1/3 <br />(11/2007) OPI =320 <br />(Page 12) U.S. DEPARTMENT OF ENERGY <br />ENVIRONMENTAL QUESTIONNAIRE <br />W. CERTIFICATION BY PROPOSER <br />I hereby certify that the information provided herein is current, accurate, and complete as of the date shown immediately <br />below. <br />SIGNATURE:E DATE ( mm/dd/yyyy): <br />TYPED NAME: <br />TITLE: <br />ORGANIZATION: <br />REVIEW AND APPROVAL BY DOE <br />I hereby certify that I have reviewed the information provided in this questionnaire, have determined that all questions have <br />been appropriately answered, and judge the responses to be consistent with the efforts proposed. Based on the information in <br />the questionnaire, I conclude the following (check the appropriate box): <br />❑ The proposed action falls under one or more of the categorical exclusions (CXes) listed in Appendix A or B of <br />Subpart D of the DOE NEPA Implementing Procedures and would not (1) violate' applicable ES &H requirements, <br />(2) require siting of waste transportation, storage and disposal or recovery facilities, (3) disturb hazardous materials <br />(excluding naturally occurring petroleum and natural gas), thus producing uncontrolled or unpermitted releases, and <br />(4) adversely affect environmentally sensitive resources. <br />Additionally, the proposed action (1) would not present any extraordinary circumstances such that the action might <br />have a significant impact upon the human environment, (2) is not connected to other actions with potentially <br />significant impacts, and (3) is not related to other actions with cumulatively significant impacts. <br />Based on the Environmental Questionnaire and these conclusions, Categorical Exclusion of the proposed action <br />would be appropriate. <br />❑ The proposed action does not qualify as a CX as identified in Subpart D of DOE's NEPA Implementing Procedures; <br />therefore, the proposed action may require further documentation in the form of an Environmental Assessment of <br />Environmental Impact Statement. <br />PROJECT MANAGER <br />SIGNATURE: DATE (mm/dd/yyyy): <br />TYPED NAME: <br />12 <br />