SDC – Project Name

City/Town/County Name(s)

TN-PIN: 000000.00

Date: mm/dd/yyyy

Environmental Commitments

Commitments are involved on the project.

List of Environmental Commitments

Click here and list project-specific commitments.

STATE OF TENNESSEE

DEPARTMENT OF TRANSPORTATION

ENVIRONMENTAL DIVISION

SUITE 900 - JAMES K. POLK BUILDING

505 DEADERICK STREET

NASHVILLE, TENNESSEE 37243-0334

(615) 741-3655

Streamlined Documentation Checklist (SDC) for
NEPA Programmatic or C-List Categorical Exclusion (CE)

Memorandum
To:	Name
Title
Organization
Address
City State Zip
From:	Name
Title
Organization
Address
City State Zip
Date:	mm/dd/yyyy

Project Information
Project Name:	Project Name
Project Termini:	Project Termini
City/Town/County:	City/Town/County Name(s)
MPO/RPO/TPO Area:	MPO/RPO/TPO Area	PIN #:	000000.00

PE #	Right-of-Way #	Construction #
Federal	If known or N/A	If known or N/A	If known or N/A
State	If known or N/A	If known or N/A	If known or N/A

Per instruction from the Tennessee Department of Transportation (TDOT) Environmental Division, the following action is being proposed for processing as a:
C-List CE	Programmatic Categorical Exclusion (PCE)

Project Planning
The project is in an MPO/TPO—The relevant Transportation Improvement Program (TIP) page is included in the attachment.
The project is in an RPO—The relevant State Transportation Improvement Program (STIP) page is included in the attachment.

Project Description and Need
Click here and include a description of the program, the project and its setting.

Review Criteria	NO	YES
1	Right-of-Way—Does the proposed action require the acquisition of more than 1.0 acre of right-of-way or permanent easements, or involve displacements of any commercial or residential occupants?
2	Access Control—Does the proposed action involve a change in access control?
3A	Streams/Wetlands—Does the proposed action require a U.S. Coast Guard construction permit or an Individual U.S. Army Corps of Engineers Section 404 permit?
3B	Streams/Wetlands—Does the proposed project involve impoundment (surface area of 10 acres or more), diversion, channel deepening, or other modification of a stream or other water body as regulated by the Fish and Wildlife Coordination Act?
4	Endangered Species—Does the proposed action result in adverse impacts to endangered species and/or critical habitat of species protected by the Endangered Species Act?
5	Floodplain/Floodway—Does the proposed action involve work encroaching on a regulatory floodway or work affecting the base floodplain (100-year flood) elevations of a water course or lake?
6A	Farmland—Does the project convert farmland to a transportation use?
6B	Farmland—If the answer to 6A is YES, do the total points on the National Resources Conservation Service Farmland Conversion Impact Rating Form equal 160 or greater?
7	Wild and Scenic Rivers—Does the proposed action involve construction in, across, or adjacent to a river designated as a component of the National System of Wild and Scenic Rivers?
8	Air Quality—Will an Air Quality Analysis be needed?
9	Noise—Is the proposed action a Type I highway project?
10	Section 4(f)—Does the proposed action involve the use of properties protected by Section 4(f) (49 USC 303)?
11	Section 6(f)—Does the proposed action involve use of park land funded through the Land and Water Conservation Fund Act of 1965?
12	Cultural Resources (Architectural/Historical and Archaeological)—Does the proposed action have a Section 106 Adverse Effect on properties eligible for or listed in the National Register of Historic Places?
13	Native American Coordination—If the project required Native American coordination, were any responses received from the tribes indicating possible controversy?
14	Hazardous Materials—Does the proposed action affect a known hazardous materials site?
15	Environmental Justice—Does the proposed action result in disproportionately high and adverse human health or environmental effects on minority or low-income populations as defined in the Environmental Justice Executive Order 12898 and in FHWA Order 6640.23A?
16	Other—Are there other issues of concern?

If the answer to all of the above questions is NO, the proposed action qualifies for processing as a Programmatic or C-List Categorical Exclusion. This checklist should now be completed, signed, and submitted to the TDOT Environmental Division for review and concurrence.
If the answer to any of the above questions is YES, contact the TDOT point of contact to confirm the level of environmental documentation. If the impacts/effects are not significant, the proposed action may still be processed as a Programmatic or C-List Categorical Exclusion.

Preparer’s Certification
I hereby certify that I have read and understand the Instructions for the Preparation of the NEPA Streamlined Documentation Checklist (SDC) for Programmatic or C-List Categorical Exclusions. I also certify that I have read and understand the Programmatic Categorical Exclusion Agreement between the FHWA –Tennessee Division and TDOT. This document has been reviewed for compliance with applicable federal, state, and local laws and regulations. It has been prepared in compliance with the Council on Environmental Quality Regulations for Implementing the Procedural Provision of the National Environmental Policy Act, 40 CFR 1500–1508, 23 CFR 771, and the Tennessee Environmental Procedures Manual. I hereby certify that I have read and understand 23 CFR 771.117(c). This document has been prepared by experienced, technically competent, and knowledgeable professionals. I can attest to the document’s quality, accuracy, and completeness. By signing this document I am further certifying that, to the best of my knowledge, it meets the criteria for a Programmatic or C-List Categorical Exclusion.

Prepared by:	mm/dd/yyyy
Name
Title
Organization or Firm
Phone
Email
Local Government Representative Signature (if prepared by local government):	mm/dd/yyyy
Name
Title
Organization
Phone
Email

FOR TDOT ENVIRONMENTAL DIVISION USE ONLY

C-List CE	The TDOT Environmental Division has reviewed the proposed project for compliance with environmental laws and regulations. It is our determination that the project will not, either individually or cumulatively, have any significant environmental impacts. This project meets the criteria of a Categorical Exclusion under 23 CFR 771.117(c) and therefore does not normally require further NEPA approvals by FHWA.
PCE	The TDOT Environmental Division has reviewed the proposed project for compliance with environmental laws and regulations. It is our determination that the project will not, either individually or cumulatively, have any significant environmental impacts. This project meets the criteria of a Categorical Exclusion under 23 CFR 771.117(d), and complies with the most recent Programmatic Categorical Exclusion Agreement executed by TDOT and FHWA.

Reviewed by:	mm/dd/yyyy
Name
Title
Approved by:	mm/dd/yyyy
Name
Title

cc:

Additional Information (Preparer to provide additional information as necessary)

1.	Right-of-Way
Click here and list any additional information, including a list of any material included in the attachment.

2.	Access Control
Click here and list any additional information, including a list of any material included in the attachment.

3.	Streams/Wetlands
Click here and list any additional information, including a list of any material included in the attachment.

4.	Endangered Species
Click here and list any additional information, including a list of any material included in the attachment.

U.S. Fish and Wildlife Service (USFWS) Memorandum of Agreement applies. If marked, the following three checkboxes would not apply.
The proposed project has been coordinated with the USFWS Endangered Species Office. The USFWS response dated mm/dd/yyyy stated click here and include USFWS statement of response.
The proposed project has been coordinated with the Tennessee Wildlife Resources Agency (TWRA). The TWRA response dated mm/dd/yyyy stated click here and include TWRA statement of response.
The proposed project has been coordinated with the Tennessee Department of Environment and Conservation (TDEC), Division of Natural Areas. The TDEC response dated mm/dd/yyyy stated click here and include TDEC statement of response.

5.	Floodplain/Floodway
Click here and list any additional information, including a list of any material included in the attachment.

6.	Farmland
Click here and list any additional information, including a list of any material included in the attachment.

7.	Wild and Scenic Rivers
Click here and list any additional information, including a list of any material included in the attachment.

8.	Air Quality
Click here and list any additional information, including a list of any material included in the attachment.

9.	Noise
Click here and list any additional information, including a list of any material included in the attachment.

10.	Section 4(f)
Click here and list any additional information, including a list of any material included in the attachment.

11.	Section 6(f)
Click here and list any additional information, including a list of any material included in the attachment.

12.	Cultural Resources (Architectural/Historical and Archaeological)
Click here and list any additional information, including a list of any material included in the attachment.

Tennessee State Historic Preservation Office (SHPO)/TDOT Memorandum of Understanding applies. If marked, the checkbox below does not apply.
The proposed project has been coordinated with the SHPO. The SHPO response dated mm/dd/yyyy stated click here and include SHPO statement of response.

13.	Native American Coordination
Click here and list any additional information, including a list of any material included in the attachment.

14.	Hazardous Materials
Click here and list any additional information, including a list of any material included in the attachment.

15.	Environmental Justice
Click here and list any additional information, including a list of any material included in the attachment.

16.	Other
Click here and list any additional information, including a list of any material included in the attachment.

Commitments
Commitments are involved on the project and the list is found on the Environmental Commitments Green Sheet.
Commitments are not involved on the project.

Attachments