SF_F_NCN000420725_20230919_FRB_PASI(3)

OLEM 9355.1-119 February 2018
Pre-CERCLA Screening Checklist/DecisionForm
This form is used in conjunction with a site map and any additional information required by the EPA Region to
document completion of a Pre-CERCLA Screening (PCS). The form includes a decision on whether a site should
be added to the Superfund program’s active site inventory for further investigation. This checklist replaces
Attachment A in the December 2016 PCS Guidance document. A current version of the PCS checklist and
additional information is available at: https://www.epa.gov/superfund/pre-cercla-screening.
Region: State/Territory: Tribe:
EPA ID No. (If Available)
Site Name:
Other Site
Name(s):
Site Location:
(Street)
Congressional
District
(City) (State/Terr.) (County) (Zip+4) (No Zip
Available)
If no street address is available:
Checklist Preparer: (Township-Range) (Section)
(Name / Title) (Date)
(Organization) (Phone)
(Street) e-Mail -
(City) (State/Terr.) (County) (Zip+4)
Site Contact Info/Mailing Address:
CERCLA 105d Petition for Preliminary Assessment? If Yes, Petition Date (mm/dd/yyyy):
If Yes, RCRA Info Handler ID #: RCRA Subtitle C Site Status: Is site in RCRA Info?
Ownership Type: Additional RCRA Info ID #(s):
Site Type: State ID #(s):
Other ID #(s): Site Sub-Type:
Federal Facility? Federal Facility Owner:
Formerly Used Defense Site (FUDS)?
Federal Facility Docket? If Yes, FF Docket Listing Date (mm/dd/yyyy):
Federal Facility Docket Reporting Mechanism:
Native American Interest? If Yes, list Tribe:
Additional Tribe (s):
Additional Tribe (s):
PRE-CERCLA SCREENING CHECKLIST/DECISION FORM 1

Decimal Degree West (e.g., 77.036783)

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OLEM 9355.1-119 February 2018
Site Description
Use this section to briefly describe site background and conditions if known or (easily) available, such as:
operational history; physical setting and land use; site surface description, soils, geology and hydrogeology;
source and waste characteristics; hazardous substances/contaminants of concern; historical releases,
previous investigations and cleanup activities; previous regulatory actions, including permitting and
enforcement actions; institutional controls; and community interest.
Geospatial Information
Latitude: Longitude:
Decimal Degree North (e.g., 38.859156)
Provide 4 significant digits at a minimum, more if your collection method generates them.
Except for certain territories in the Pacific Ocean, all sites in U.S. states and territories are located within the northern and
western hemispheres and will have a positive latitude sign and negative longitude sign. Coordinate signs displayed above are
based on the State/Territory entry on page A-1. Geospatial data tips from the PCS Guidance document are available here.
PointDescription:Select the option below that best represents the site
point for future reference and to distinguish it from any nearby sites.
See additional information here.
Geocoded (address-matched) Site Address
Site Entrance (approximate center of curb-cut)
Approximate Center of Site
Other Distinguishing Site Feature (briefly describe):
Point Collection Method: Check the method used to collect the coordinates
above and enter the date of collection. See additional information here.
Online Map Interpolation
GPS (handheld, smartphone, other device or technology with
accuracy range 25 meters)
GPS Other (accuracy range is ≥ 25 meters or unspecified)
Address Matching: Urban
Address Matching: Rural
Other Method (briefly describe below):
Collection Date (mm/dd/yyyy):
PRE-CERCLA SCREENING CHECKLIST/DECISION FORM
POINT-SELECTION CONSIDERATIONS
Often the best point is a feature
associated with the environmental
release or that identifies the site visually.
Use the curb cut of the entrance to the
site if there is a clear primary entrance
and it is a good identifier for the
overall location.
The approximate center of the site (a
guess at the centroid) is useful for
large-area sites or where there are no
appropriate distinguishing features.
Use the geocoded address if that is
the only or best option available, but if possible use something more
representative for sites larger than 50
acres.
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OLEM 9355.1-119 February 2018
Complete this checklist to help determine if a site should be added to the Superfund
Active site inventory. See Section 3.6 of the PCS guidance for additional information. YES NO Unknown
1. An initial search for the site in EPA’s Superfund active, archive and non-site
inventories should be performed prior to starting a PCS. Is this a new site that does
not already exist in these site inventories?
2. Is there evidence of an actual release or a potential to release?
3. Are there possible targets that could be impacted by a release of contamination at
the site?
4. Is there documentation indicating that a target has been exposed to a hazardous
substance released from the site?
5. Is the release of a naturally occurring substance in its unaltered form, or is it
altered solely through naturally occurring processes or phenomena, from a location
where it is naturally found?
6. Is the release from products which are part of the structure of, and result in
exposure within, residential buildings or business or community structures?
7. If there has been a release into a public or private drinking water supply, is it due to
deterioration of the system through ordinary use?
8. Are the hazardous substances possibly released at the site, or is the release itself,
excluded from being addressed under CERCLA?
9. Is the site being addressed under RCRA corrective action or by the Nuclear
Regulatory Commission?
10. Is another federal, state, tribe or local government environmental cleanup program
other than site assessment actively involved with the site (e.g., state voluntary
cleanup program)?
11. Is there sufficient documentation or evidence that demonstrates there is no
likelihood of a significant release that could cause adverse environmental or
human health impacts?
12. Are there other site-specific situations or factors that warrant further CERCLA
remedial/integrated assessment or response?
PRE-CERCLA SCREENING CHECKLIST/DECISION FORM 3

OLEM 9355.1-119 February 2018
Preparer’s Recommendation: Add site to the Superfund Active site inventory.
Do not add site to the Superfund Active site inventory.
Please explain recommendation below:
PCS Summary and Decision Rationale
Use this section to summarize PCS findings and support the decision to add or not add the site to the Superfund active site inventory for further investigation. Information does not need to be specific but, where
known, can include key factors such as source and waste characteristics (e.g., drums, contaminated soil);
evidence of release or potential release; threatened targets (e.g., drinking water wells); key sampling results (if
available); CERCLA eligibility; involvement of other cleanup programs; and other supporting factors. Attach
additional pages as necessary.
Checklist Preparer Name Checklist Preparer Organization
EPA Regional Review and Pre-CERCLA Screening Decision
Add site to the Superfund active site inventory for completion of a:
Standard/full preliminary assessment (PA) Abbreviated preliminary assessment (APA)
Combined preliminary assessment/site inspection (PA/SI) Inegrated removal assessment and preliminary assessment Integrated removal assessment and combined PA/SI Other:
Do not add site to the Superfund active site inventory. Site is:
Not a valid site or incident
Being addressed by EPA’s removal program
Being addressed by a state cleanup program
Being addressed by a tribal cleanup program
Being addressed under the Resource Conservation and Recovery Act
Being addressed by the Nuclear Regulatory Commission
Other:
Date
Optional-PrintnameofEPASiteAssessormaking thisdecision:
EPA Regional Approval: (Enter Date and then click this box to Date
initiate digital signature stamp)
PRE-CERCLA SCREENING CHECKLIST/DECISION FORM 4

OLEM 9355.1-119 February 2018
Site Description
(All text as entered on page A-2)
PRE-CERCLA SCREENING CHECKLIST/DECISION FORM 5

OLEM 9355.1-119 February 2018
PCS Summary and Decision Rationale
(All text as entered on page A-4)
PRE-CERCLA SCREENING CHECKLIST/DECISION FORM 6