VPP SELF-ASSESSMENT CHECKLIST

The items listed below will help you gauge your eligibility for VPP. Check each item you
currently have or are willing to implement. This self assessment should give you a good
idea of what you may need to do to improve your safety and health management system
and qualify for VPP.

Call the VPP Manager or Coordinator in your OSHA Regional or Area Office if you have
questions about VPP requirements or the application process. Even if you dont have
questions, its a good idea to let OSHA know you are considering applying. You will find a
listing of OSHA offices online at www.osha.gov.

Rates
For the most recent 3 full calendar years, calculate (1) your Total Case Incidence
Rate (TCIR) for recordable nonfatal injuries and illnesses, and (2) your incidence
rate for recordable injury and illness cases involving Days Away from Work,
Restricted Work Activity, and/or Job Transfer (DART rate).

General Industry, Maritime, and Federal Agencies: Compare your 3-year

injury/illness rates with the 3 most recent years of specific industry national
averages for nonfatal injuries and illnesses, at the most precise level OSHA will
compare all submitted rates against the most recent single year that would qualify
you out of the last 3 published years. If your 3-year TCIR, DART rate, or both are
at or above your industry average, you must have a plan to reduce rates to below
the industry average. It must be feasible to reduce rates to below the industry
average within 2 years. If you are a small business, you may be eligible for the
alternative rate calculation. Contact your Regional VPP Manager or Coordinator, or
review the VPP Federal Register Notice of December 24, 2003 (68 FR 68475) for
more details.

Construction only: For long-term construction projects applying to the

traditional VPP, the two calculated rates must include all workers at the site,
whether or not they are your own employees. From site inception until time of
application, but no less than 12 months, rates must be below the BLS national
average for the type of construction at your site. Applicants to the VPP Mobile
Workforce Demonstration for Construction should consult the application
instructions for the Demonstration.

If site rates are at or above the industry average, a construction applicant may
qualify for traditional VPP by demonstrating that the companys 3-year nationwide
rates for work in the applicant sites NAICS code, or rates for a geographic area
approved by OSHA, are below the industry average.

Management Leadership and Employee Involvement

A managerial commitment to worker safety and health protection.

Top site managements personal involvement.

A system in place to address safety and health issues/concerns during overall

management planning/purchasing/contracting.

Safety and health management integrated with your general day-to-day

management system.
 A written safety and health management system often referred to as a safety
and health manual with policy and procedures specific to your site appropriate
for your sites size and your industry, that addresses all the elements in this
checklist.

A safety and health policy communicated to and understood by employees.

Safety and health management system goals and results-oriented objectives for
meeting those goals.

Clearly assigned safety and health responsibilities, with documentation of

authority and accountability from top management to line supervisors to site
employees.

Necessary resources to meet responsibilities, including access to certified safety

and health professionals, other licensed health care professionals, and other
experts, as needed.

Selection and oversight of contractors that ensure effective safety and health
protection for all workers at the site.

At least three ways employees are meaningfully involved in activities and

decision-making that impact their safety and health. These must be in addition to
your system of hazard reporting.

Annual safety and health management system evaluations on VPP elements in a

narrative format, recommendations for improvements, and documented follow-
up.

Formal signed statements from all collective bargaining agents indicating support
of your application to VPP.

Where no collective bargaining agent is authorized, written assurance by

management that employees understand and support VPP participation.

Worksite Analysis
A baseline hazard analysis identifies and documents common hazards associated
with your site, such as those found in OSHA regulations, building codes, and other
recognized industry standards and for which existing controls are well known.

Documentation within the baseline hazard analysis of your sampling strategy to

identify health hazards and accurately assess employees exposure, including
duration, route, frequency of exposure, and number of exposed employees.

Hazard analysis of routine jobs, tasks, and processes that identifies uncontrolled
hazards and leads to hazard elimination or control.

Hazard analysis of significant changes, including non-routine tasks, new

processes, materials, equipment, and facilities, that identifies uncontrolled
hazards prior to the activity or use and leads to hazard elimination or control.

Samples, tests, and analyses that follow nationally recognized procedures.

Self-inspections that cover the entire site at least quarterly (weekly for
construction). Conducted by trained staff, with written documentation and hazard
 correction tracking.

A written hazard reporting system that enables employees to

report their observations or concerns to management without fear of
reprisal, and
receive timely responses.
Accident/incident investigations conducted by trained staff. Written findings that
aim to identify all contributing factors.

A system that analyzes injury, illness, and related dataincluding inspection

results, observations, near-miss and incident reporting, first aid, and injury and
illness recordsto identify common causes and needed corrections in procedures,
equipment, or programs.

Hazard Prevention and Control

An effective system for eliminating or controlling hazards. This system
emphasizes engineering solutions that provide the most reliable and effective
protection. It may also utilize, in preferred order, administrative controls that limit
daily exposure, such as job rotation; work practice controls, such as rules and
work practices that govern how workers do a job safely and healthfully; and
personal protective equipment. All affected employees must understand and
follow the system.

A system for tracking hazard correction. It includes documentation of how and

when hazards are identified, controlled or eliminated, and communicated to
employees.

A written preventive/predictive maintenance system that reduces safety-critical

equipment failures and schedules routine maintenance and monitoring.

An occupational health care program appropriate for your workplace. It includes,

at a minimum, nearby medical services, staff trained in first aid and CPR, and
hazard analysis by licensed health care professionals as needed.

A consistent disciplinary system that operates for all employees including

supervisors and managerswho disregard the rules.

Written plans to cover emergency situations, including emergency and evacuation

drills for all shifts.

Safety and Health Training

Training for managers and supervisors that emphasizes safety and health
leadership responsibilities.

Training for all employees on the sites safety and health management system,
hazards, hazard controls in place, and the VPP.

Training that enables employees to recognize hazardous conditions and

understand safe work procedures.

A method for assessing employee comprehension and training effectiveness.

Documentation of all training that individual employees receive.

 COMPLETING THE SITE ASSESSMENT CHECKLIST
Suggested Tools and Materials
Cornell pH test kit and instructions shovel and trowel
soil texture by feel instructions plastic bags
 wash bottle filled with water wristwatch or timer
at least 4 gallon jugs of water weed identification manual
paper towels ornamental plant identification manual
measuring tape hand pruners
yardstick pencil/pen and extra paper
Optional tools: diameter tape, penetrometer, soil probe, vials
containing alcohol
for unknown insects, infrared thermometer
1. Site Location
Note the address of the site. You may also wish to note the nearest
cross streets and/or page and grid of the maps your firm uses.
2. Site Description
A brief overview of the site including: general use or function,
approximate size, accessibility, general topography (steep hill, gentle
slope, etc.)
3. Climate
a. USDA Hardiness Zone
Check the USDA hardiness zone of the site. If planting in
containers above ground you may want to regard the site as a
zone colder than listed, as trees in containers are more
susceptible to cold winter temperatures than trees in the
ground.
b. Microclimate Factors
Re-reflected heat load: Determine if the site, or some portion of
it, has heat pockets due to reflected and reradiated heat loads
from pavement, automobiles, buildings or other surfaces. This
can cause a tree to heat up and lose water from its leaves at a
faster than normal rate. These pockets are often south facing
and have a tremendous amount of heat load. On sunny days,
these areas will be noticeably warmer than nearby spots.
Drought-resistant trees should be chosen in these situations.
Frost pocket: Frost pockets are often found in low areas at the
bottom of a slope or bowl. Cooler air, being heavier, collects in
these areas, lowering air temperatures.
Wind: Excessively windy sites will often place stress on trees,
particularly those with large leaves which may result in leaf
tatter. Also, trees in these sites may need supplemental
watering to prevent them from drying out as quickly. Signs of
excessive wind are trees leaning or growing in the same
direction. Plants will have stunted growth on the side that faces
the full force of the prevailing wind. Wind tunnels are common in
urban areas where wind is funneled between tall buildings.
Other: Are there other factors that might affect the climate or
precipitation levels? For example, are there wide rain shadows
formed by the overhang of a building? Is the site located near a
large body of water that may moderate the climate?
c. Sunlight Levels
Shady sites determined by the sun and shade patterns around
buildings may limit the choice of trees. Consider that a site has
full sun if it receives more than 6 hours of direct sunlight. Partial
sun has direct sun (often morning sun) for less than 6 hours, or
filtered light (as would be common under a tree with fine
textured eaves) for most of the day. An area is consider shady if
it receives little or no direct sunlight, or if it receives less than 6
hours of filtered light.
 d. Irrigation Levels
Note the presence or absence of an automatic irrigation system.
If possible record the method of delivery (overhead, drip, mini-
sprinkler), the weekly amount of water applied and the rate at
which it is applied. You may wish to test the system by setting
out collection containers in different on the site and running the
system for a specified amount of time to test the delivery rate.
Comparing the actual amount delivered with the manufacturer s
specifications for the system will indicate its efficiency.
4. Soil Factors
a. Range of pH Levels
Check the pH for several areas on the site. Pay particular
attention to the pH near sidewalks and parking areas, concrete
or masonry buildings or foundations. These limestone-containing
materials in the street environment result in the high ph levels
(from neutral to alkaline) of most urban soils. Note the range of
levels on the front side of the checklist. Note the sample
locations and exact readings on the sketch on the back of the
checklist.
b. Texture
In the field, test the soil texture using the soil texture-by-feel
technique, and record the results on the checklist. If you must
know the exact soil texture, record the general soil type on the
checklist and collect several samples to be analyzed by a soils
lab. A sandy soil will suffer less from the effects of compaction
but may be less able to supply water to trees. Conversely,
compaction may render a heavy clay soil too wet, making
oxygen less available.
c. Compaction Levels
There are several ways to test for soil compaction. A simple one
is to use a penetrometer. Record the average depth of
penetration at which the probe measures 300 psi. Alternately,
you may take several soil cores using a soil probe and analyze
them for soil density. Perhaps the simplest test is to dig a small
pit and gauge the difficulty of hand digging. Repeat the shovel
test in several spots.
d. Drainage Characteristics
Determining the drainage characteristics of your site is a multi-
faceted task.
Presence of mottled soil: The strongest indication of poor
drainage is mottled soil. Dig a soil pit at least 12 to 15 deep
and remove several clods for examination. Clods that have grey
mottling and/or have a foul odor indicate poor drainage.
Low-lying topography: Study the topography for low-lying areas
that collect surface runoff and that may be poorly drained.
Indicator plants: Plants that indicate poorly drained (wet) sites
include Willow, Pin Oak, Swamp White Oak, and Tupelo. Plants
that indicate moist soils are sycamore and tulip trees. Plants that
 indicate well-drained sites are sugar maple, red oaks and
hickories.
Percolation test: To perform a percolation test, dig a pit
approximately one foot deep. Fill the pit with water and allow
this water to drain completely. Once the water has completely
drained, refill the pit with water, measure the depth of water in
the pit and note the time. After 15 minutes, note the depth of
water and calculate the rate of drainage in inches per hour. (The
initial filling and draining of the pit is to saturate the soil to test
more closely for gravitational water movement.) Classify the soil
into one of the three drainage classes: poorly drained (< 4 /hr);
moderately drained (4-8/hr); or excessively drained (> 8 /hr).
e. Other Soil Considerations
Indications of soil layer disturbance: Look for areas that show
evidence of regarding cuts or fills. Clues include mature trees
that do not show a trunk flare (due to soil piled against the
trunks), or have retaining walls near their bases. You may wish
to dig a pit approximately two feet deep in order to examine the
soil horizons, especially if the site has recently had construction
activity. Soil layers that are noticeably lighter in color than lower
layers indicate that subsoil has been spread on top of the
original grade. Conversely, the absence of a rich brown, organic
layer at the top may indicate that the topsoil has been removed.
Evidence of recent construction: Clues include newly-pave
surfaces, turf that is noticeably thinner than in surrounding
areas, new retaining walls, soil humps or subsidence, and the
like. Also consider the route or routes taken by heavy equipment
into the site and where materials were stored during
construction.
Presence of construction debris: Construction debris is likely on
almost all construction sites, particularly if tipping fees for debris
are high in your area, and if construction involved the renovation
or removal of a building or pavement.
Noxious weeds present: Use a guide to identify weeds. Pay
particular attention to perennial noxious weeds that must be
eradicated before landscape installation. Perennial weeds that
are commonly found in urban landscapes include: bindweed,
poison ivy, mugwort, wild violet, nutsedge, quackgrass, and
healall.
Evidence of excessive salt usage/salt injury: Look (particularly
near walks and parking areas) for white powder that has
precipitated out on the soil surface. Prostrate knotweed is a
weed that indicates salty compacted soil. Brown needle tips,
marginal leaf scorch, or witches broom on ornamentals indicate
salt injury. Carefully examine areas where salt-laden snow has
been dumped. These areas are likely to have high soil salt
concentrations.
Erosion of soil evident: Determine the extent and severity of soil
erosion. Note the presence and size of eroded gullies, rills, or soil
slumps. Factors that affect soil erosion include: rainfall intensity,
 quantity, and runoff; slope length and gradient; amount of
stabilizing plant material or other erosion control practices; the
infiltration rate and the structural stability of the soil.
Evidence of soil contamination: Look for signs of dumping by
restaurants or open-air food stalls of wash water, old dumping
areas, construction dumping areas, oil and gas dumping, and
the like.
Usage that compacts soil: Is the area used for open-air markets
or parties? Are there pathways that pedestrians have created? Is
the area sometimes used for parking? Are there other social
activities that are planned for the site that tend to compact the
soil?
f. Specific Soil Problems
Use this space to record specific soil problems that occur on the
site.
Problems might include an inability to surface drain a site,
possible soil chemical
contaminants, and the like.
5. Structural Factors
a. Limitations to above-ground space
Overhead wire height: Describe the location and estimate the
height of over head utility wires.
Proximity to buildings and structures: Note the location of
buildings and structures on the back of the checklist. Check the
box on the front side of the checklist if you anticipate buildings
or structures having an impact on the canopy space of
landscape plantings.
Other: Are there any other limitations to above-ground space?
Examples include: building or planting setbacks, emergency
access lanes that must be kept clear, heat vents, and signs that
must be readable from the road.
b. Limitations to below-ground space
Utilities: Mark utilities on the sketch. Identify individual utilities if
possible. Know that you must hand dig within two feet on either
side of the marked line.
Estimate rooting volume: In order to estimate the available
rooting volume of a planting site, measure the length and width
of available soil, and multiply area by the estimated depth of
rooting. Remember that compacted soil will have a very shallow
rooting depth.
6. Visual Assessment of Existing Plants
a. Species
Identify the species of plant. The more specific identification is,
the better. You may
wish to collect leaf and/or bud samples to bring back to the
office for identification of
obscure plants or plants not in leaf.
b. Size
Approximate the height and spread of the plant material using
the following field method: Place a yardstick (or other object of
 known height) against the trunk. Step back so that the whole
tree is in your sight. While holding a pencil or pen at arm s
length, line up the top of the yardstick with the tip of the pencil.
Using your thumbnail, mark the base of the ruler on the pencil.
Sighting up the tree, determine how many rulers fit into the
tree. Multiply this number by the length of the yardstick for a
height approximation. Use the same method to estimate the
canopy spread. You may also wish to note the diameter of the
trunk at breast height (4.5 above ground level).
c. Growth rate
Quantify this years annual shoot extension by measuring the
twig length between growth tip (terminal bud) and the bud scale
scar. Past years growth is the length between bud scales.
Measure several branches growing in the sun in the upper 2/3 of
the canopy. Record the average growth rate. Less than 2 of
growth is considered poor, 2 to 6 is moderate growth, and
greater than 6 per year is vigorous growth.
d. Visual Assessment
In general: Note aesthetic quality and general health of each
plant. Indicate mechanical injury to plant parts. Also note the
presence of insects or disease. Keep in mind that diseases and
insects often attack stressed trees and may not be the primary
cause of health problems.
Trunk assessment: Look for evidence of mower or string trimmer
damage at the base of the trunk. Also look for excessive
suckering or bark splitting. Note any trees that do not exhibit a
trunk flare (indicative of recent regrading activity or that it was
planted too deep).
Roots: Note excessive surface rooting and girdling roots. These
may signify poor drainage, too-deep planting, and/or compacted
soils. Test the stability of newly planted trees by gently rocking
them. If there is excessive movement, the trees may have root
problems, or the roots were never able to establish after
transplanting.
Leaves and branches: Stressed trees often exhibit small, off-
color leaves that drop early in the fall. Also note trees whose
leaves show marginal leaf scorch and whose branches have tip
die-back. If there is significant die-back, is it all on one side of
the canopy or is it on both sides? Do all of one species on the
site exhibit the same symptoms? Note the presence of witches
broom, watersprouts, or other abnormalities.
ENVIRONMENTAL IMPACT ASSESSMENT CHECKLIST
NOTE: This Worksheet is for projects that have minor and predictable impacts and
require a Part 5
assessment. See CEPG2295 for information on completing this worksheet. Steps 1-12
are described in this document. See CEPG2016 for further information on Part 5
assessments and assessments under
Parts 3A and 4 of the EP&A Act.
Project Name Project Number
Project Location Assessment Version
CONSTRUCTION WORK MUST NOT COMMENCE
UNLESS:
The Determining Officer has signed this document, verifying that each of the steps
has been
satisfied and no further assessment, investigation or further referral to an Appropriate
Officer
within Country Energy is required, AND
All relevant construction personnel are aware of:
Their responsibilities detailed in CEPG2295, CEPG2016 and other relevant Country
Energy policies
The projects Environmental Impacts in TABLE 4
The projects specific Control Measures in TABLE 4
The projects environmentally Sensitive Areas in TABLE 3
The conditions in any approvals, licences or permits in TABLE 2
The project details and likely impact of the project on the community
NOTE: If any environmental issues are identified or if any environmental control
measures are
required, a copy of TABLE 4 from this completed EIA Worksheet, detailing control
measures,
MUST be included in the construction work pack that is submitted to the
Construction Manager
for the project.
NOTE: Projects requiring a more detailed assessment must be referred to relevant
officer within
Country Energy. Refer to Country Energys delegations table at Appendix F of
CEPG2016 for further
details on responsibilities for EIA.
NOTE: Projects requiring a Part 3A or Part 4 planning approval must be referred to the
relevant consent
authority.
NOTE: For further details of assessing whether a project requires approval under Part
3A or Part 4,
refer to CEPG2295 and CEPG2016.
FORM ENVIRONMENTAL IMPACT ASSESSMENT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 2 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
TABLE 1 PROJECT DETAILS
Project justification
Description of those activities of the project
which are being assessed under Part 5 of the
EP&A Act:
(include ancillary activities such as future
maintenance, street lighting, access tracks,
fences, tree trimming, etc. and include all
mitigation measures)
Sufficiently described in project documentation.
OR
Description of timings, phasing and schedules: Sufficiently described in project
documentation.
OR
Ownership of the relevant land (noting whether
Country Energy owns the land, easements will
be required for works, access will be required
or native title issues)
Sufficiently described in project documentation.
OR
Description of the environment relevant to the
potential impacts.
(This could include drainage systems,
waterways, flora and fauna, visual/scenic
quality, transportation routes, land use, traffic
flow, land contamination etc.)
Sufficiently described in project documentation.
OR
Description of types and quantities of waste. Sufficiently described in project
documentation.
OR
Description of relevant Environmental Planning
Instruments.
(This could include LEPs, REPs, or SEPPs and
if necessary, the relevant zoning, clause,
provision or schedule)
Route/Site Option Justification:
(It may be necessary to revisit this step after
identifying any project specific Control
Measures in STEP 6)
No other possible options for route / site
OR
Sufficiently described in project documentation.
OR
What EMF prudent avoidance measures have
been implemented for the siting of powerlines
and substations?
(Low/no cost options might include: locating the
infrastructure further from receivers, group
cables together, locating low voltage side of the
substation furthest from receivers etc.)
Describe:
What is the likelihood of the project affecting
the community?
Low, Medium, High
What is the ability of the community to
contribute to the site selection or route
selection?
Low, Medium, High
Description of community consultation
(Consultation methods should be added to
Project Controls in Table 4.)
None
OR
NOTE: Projects with a HIGH community impact must be referred to the Appropriate
Officer at Country
Energy.
STEPS 1-2
FORM ENVIRONMENTAL IMPACT ASSESSMENT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 3 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
TABLE 2 APPROVALS, LICENCES and PERMITS
TRIGGER AREAS INCLUDE: Tick one
Working near Endangered, Threatened, Vulnerable or Protected Species, Populations, Ecological
Communities or Critical Habitat (Flora and Fauna) National Parks and Wildlife Service, NSW
Fisheries, Department of Primary Industries.
Yes, No
Working within a national park, nature reserve, aboriginal area, wilderness area, conservation
area
or wild river Department of Environment and Conservation, National Parks and Wildlife
Service.
Yes, No
Working near Areas of National Environmental Significance (RAMSAR Wetlands, threatened
species, migratory birds, World Heritage, National Heritage, nature reserve etc.) or on
Commonwealth land or marine area Department of Environment and Heritage (Cth).
Yes, No
Working near areas protected by State Environmental Planning Policies for conservation
purposes
(eg SEPP 14 Coastal Wetlands, SEPP 26 Littoral Rainforests) Department of Natural
Resources, Department of Environment and Conservation, Department of Planning.
Yes, No
Working within an area that is subject to any conservation agreement entered into under the
National Parks and Wildlife Act 1974 Department of Environment and Conservation,
National Parks and Wildlife Service.
Yes, No
Working within an area that is subject to any plan of management under the National Parks and
Wildlife Act 1974 Department of Environment and Conservation, National Parks and
Wildlife Service.
Yes, No
Working within an area that is subject to any joint management agreement under the National
Parks and Wildlife Act 1974 Department of Environment and Conservation, National Parks
and Wildlife Service.
Yes, No
Working near an aquatic reserve or Marine Vegetation such as seagrass, mangroves etc
Fisheries NSW. Yes, No
Dredging of water Fisheries NSW, Waterways or Department of Primary Industries. Yes,
No
Working within a Special Area declared in the Sydney Water Catchment Management Act
Sydney Catchment Authority. Yes, No
Working within the place of a Heritage Item identified on the Register of the National Estate,
under the NSW Heritage Act or an environmental planing instrument Heritage Council, Local
Council.
Yes, No
Working within the place of a Heritage Item as defined in other register Heritage Council.
Yes, No
Working where a Relic is likely to be discovered (eg Archaeological Zoning Plans) Heritage
Council or National Parks and Wildlife Service. Yes, No
State Forest or area subject to Forest Agreement Forests NSW, Department of Environment
and Heritage (Cth). Yes, No
Working near aboriginal relics or places National Parks and Wildlife Service. Yes, No
NOTE: Projects requiring approval, licence or permit because of a Trigger Areas (above)
must be
referred to the Appropriate Officer at Country Energy.
STEP 3
FORM ENVIRONMENTAL IMPACT ASSESSMENT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 4 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
OTHER AREAS INCLUDE:
Generating, handling, storing, transporting or disposing of hazardous, industrial or Group A waste
or controlled waste Environment Protection Authority and Local Council (eg wastes such
as pesticides, lead, radioactive relays, contaminated soil etc.).
Yes, No
Handling, storing, transporting or disposing of Dangerous Goods Environment Protection
Authority and WorkCover. Yes, No
Handling, transporting or disposing of Controlled Chemicals such as PCBs, OCPs etc
Environment Protection Authority and WorkCover. Yes, No
Discharging anything to a waterway or stormwater drain Environment Protection Authority
and Local Council. Yes, No
Discharging Trade Waste to the sewer Relevant water authority, Local Council. Yes,
No
Clearing native vegetation, State protected lands, lands protected by a Regional Vegetation
Management Plan (Property Vegetation Plan) or carrying out works involving trees covered by a
tree preservation order. State protected lands include Category A (generally > 1 hectare and >
18o slope) or Category B (generally within 20m of a river) Department of Natural Resources,
Local Council.
Yes, No
Working on a classified road including freeway, highway, main road, tourist road etc. Roads
and
Traffic Authority or Local Council. Yes, No
Removing or lopping trees from Crown-timber lands Forestry NSW Yes, No
Working within a Mine Subsidence District Mine Subsidence Board Yes, No
Construction of pipelines Relevant energy authority
Water management works Department of Natural Resources Yes, No
Using flames during a Total Fire Ban or working within bushfire protected lands NSW Rural Fire
Service. Yes, No
Working on Crown Lands Department of Lands. Yes, No
Other please specify: Yes, No
Description of area/issue identified
above:
NOTE: If you have ticked any Yes above then you must either:
1 Attach a copy of the approval, licence or permit to the final EIA Worksheet, OR
2 Detail who is responsible for obtaining
the approval, licence or permit, OR
3 Explain why the project is exempt.
Date Council was notified:
NOTE: You must give council 40 days notice before carrying out electricity works
(excluding
maintenance and emergency repairs) and give due consideration to any submission.
This requirement
only applies to road or public reserves.
FORM ENVIRONMENTAL IMPACT ASSESSMENT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 5 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
TABLE 3 OTHER SENSITIVE AREAS/ISSUES
TRIGGER AREAS INCLUDE: Tick one
Wildlife corridors/refuges, native forests, Wildlife Management Areas, Significant Tree Registers
(council), Koala Habitat (>1 hectare of bushland). Yes, No
Siting oil filled equipment within 40m of a sensitive area (waterways, National parks etc.) or 5m
upstream of a drain. Yes, No
Decommissioning substations (may require a contaminated site assessment). Yes, No
Installation of SF6 equipment in distribution substations. Yes, No
Areas with contaminated soil or water (ground or surface) or degraded air quality or Unhealthy
Building Land Notice. Yes, No
Areas subject to land rights claims or Registered Native Title or Register of Indigenous Land Use
Agreements. Yes, No
NOTE: Projects affecting or traversing a Trigger Area (above) must be referred to the
Appropriate
Officer at Country Energy.
OTHER AREAS INCLUDE:
Areas or items of high architectural, historical, environmental protection or scientific value. Yes,
No
Environmental Protection Zones as defined by environmental planning instruments (eg foreshore
scenic protection areas, conservation areas, scenic protection areas, beachfront scenic
protection areas etc.).
Yes, No
Coastline and dune fields, alpine areas, deserts, caves, wetlands (not state significant) or other
unique landforms. Yes, No
Areas or items of high aesthetic or scenic value. Yes, No
Recreational areas (beaches, foreshores, parks, picnic areas, lookouts, national features, tourist
areas, tourist roads/routes etc.). Yes, No
Excavating near a river, lake, lagoon, wetland, drinking water catchment or flood prone area
(within 40m). Yes, No
Excavating near a gutter, stormwater channel, drain or inlet (within 40m up stream). Yes, No
Use of Group A construction equipment in an urban area. Yes, No
Erosion prone areas. Yes, No
Areas containing acid sulphate soils. Yes, No
Cafes, restaurants, shops, outdoor dining, Pubs, places of worship etc. __________Yes, No
Bush regeneration areas, dune regeneration areas etc. Yes, No
Areas of high bushfire risk. Yes, No
Noxious Weeds (categories W1-W4). Yes, No
Urban bushland or remnant roadside vegetation. Yes, No
Major transport corridors (Highways, freeways, railways, shipping channels, airports etc.). Yes,
No
Major pedestrian routes (eg foreshore walks, around sporting venues etc.). Yes, No
Schools, childcare centres, playgrounds etc. Yes, No
Other - please specify:
Yes, No
Description of sensitive areas
identified above:
STEP 4
FORM ENVIRONMENTAL ASSESSMENT IMPACT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 6 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
TABLE 4 ENVIRONMENTAL IMPACT ASSESSMENT
Project Issue Examples of impacts Description of Impacts AND Causes Specific Control
Measures
NOTE: Either tick minor OR provide
details. Key section (s)
of CEPG5041
Additional controls
Likelihood
Extent
Sensitivity
Environmental
Score
Dust generation (excavating, disturbing soil,
stockpiling, trenching, erosion prone sites, clearing
of vegetation, transporting soil etc.).
AIR
Fumes, odours and other air pollution from vehicles,
equipment, machinery or other activities (eg. Spray
booths, mobile oil processors, incinerators, waste
storage areas, SF6, oxy acetylene, confined spaces
gases, etc.).
Minor
If ticked,
go to
next
issue.
OR
Polluting waterways, wetlands, stormwater drains or
groundwater (eg storing, transporting, handling or
disposing of oils, PCBs, fuels, pesticides, chemicals,
pit/trench water or other liquids).
WATER
Sedimentation of waterways, wetlands, stormwater
drains or groundwater (eg excavating, disturbing
soil, stockpiling, trenching, concrete cutting, access
tracks, erosion prone sites etc.).
Minor
If ticked,
go to
next
issue.
OR
Construction noise/vibration (eg rockbreakers,
concrete cutters, jackhammers, chainsaws,
compressors, excavators, backhoes, trucks,
vehicles, AH work, cranes, steel plates movements,
generator etc.).
NOISE AND
VIBRATION
Operational noise/vibration (eg transformers, circuit
breakers, powerline corona, tap changers, CLCs
etc).
Minor
If ticked,
go to
next
issue.
OR
STEP 5
(1-3)
(1-3)
(1-3)
(1-27)
STEP 6
STEP 7
STEP 8
STEP 9
STEP 10

XX=
FORM ENVIRONMENTAL ASSESSMENT IMPACT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 7 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
Project Issue Examples of impacts Description of Impacts AND Causes Specific Control
Measures
NOTE: Either tick minor OR provide
details. Key section (s)
of CEPG5041
Additional controls
Likelihood
Extent
Sensitivity
Environmental
Score
Disturbing contaminated soil (eg known
contamination, ASS, old industrial site, previous
landfill etc.).
Contaminating or polluting land (eg storing, handling
or disposing of oils, PCBs, fuels, pesticides,
chemicals, pit/trench water or other liquids).
CONTAMINATION AND
WASTE
Environmental problems caused by generating,
storing, handling, transporting or disposing of waste
(eg soils, building materials, power poles, oils,
solvents, streetlights etc.).
Minor
If ticked,
go to
next
issue.
OR
Restricting current and potential activities associated
with the land (eg amenity, buildings, parking,
interference with radios, TVs or VDUs etc.).
LAND USE AND
TRANSPORT
Restricting or affecting transport (eg pedestrian, car,
bus, train, airports, boats, river crossings, bus stops,
public transport corridors and infrastructure,
construction related disturbances, property access,
parking restrictions, etc.).
Minor
If ticked,
go to
next
issue.
OR
Displacing, disturbing or damaging terrestrial or
aquatic fauna (eg creating a barrier to fauna
movement, clearing remnant vegetation or wildlife
corridors, electrocution, collisions etc.).
Clearing or modifying native vegetation (including
trees, shrubs, grasses, roots, herbs or aquatic
species).
Introducing or spreading weeds (inc noxious) or
vermin.
Introducing bushfire risk factors.
Endangering any species of animal, plant or other
form of life, whether living on land, in water or in the
air (eg. any danger to birds in the locality).
FLORA AND FAUNA
Any other environmental impacts on the ecosystems
of the locality.
Minor
If ticked,
go to
next
issue.
OR
FORM ENVIRONMENTAL ASSESSMENT IMPACT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 8 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
Project Issue Examples of impacts Description of Impacts AND Causes Specific Control
Measures
NOTE: Either tick minor OR provide
details. Key section (s)
of CEPG5041
Additional controls
Likelihood
Extent
Sensitivity
Environmental
Score
Creating a risk to people (eg electrocution, trenches,
fires, dangerous goods, service outages, noise, EMF
guidelines etc.).
Creating a nuisance to the community (eg perceived
risk of fires, explosions, property value devaluation
etc.).
SOCIAL
Creating financial loss to members of the community
(eg. restricting access to commercial premises,
changing land use etc.).
Minor
If ticked,
go to
next
issue.
OR
Affecting a locality, item, place or building having
aesthetic, anthropological, archaeological,
architectural, historical, scientific, cultural or social
significance or other special value (eg. visual effect
on adjoining heritage buildings or items, disturb,
move excavate Aboriginal object) or working where
heritage items could be found (eg Archaeological
Zoning Plans).
Affecting any Aboriginal heritage (eg engravings,
middens, carved trees, grinding grooves, paintings,
burial sites, etc.).
Changing the visual or scenic landscape (eg
restricting views, removing trees, installing OH
powerlines, installing substations, causing obtrusive
lighting, creating shadows etc.).
VISUAL AND HERITAGE
Transforming a locality (e.g. significant earthworks).
Minor
If ticked,
go to
next
issue.
OR
FORM ENVIRONMENTAL ASSESSMENT IMPACT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 9 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
Project Issue Examples of impacts Description of Impacts AND Causes Specific Control
Measures
NOTE: Either tick minor OR provide
details. Key section (s)
of CEPG5041
Additional controls
Likelihood
Extent
Sensitivity
Environmental
Score
Long-term effects on the environment (e.g. as a
result of waste emissions).
Degrading of the quality of the environment (e.g.
effect on surrounding bushland, contamination,
erosion).
Any other risk to the safety of the environment (e.g.
from exceeding the relevant EMF guidelines and
having regard to principles of prudent avoidance ).
Reducing the range of beneficial uses of the
environment (e.g. effect on surrounding land-uses
and considering response of affected land owners).
Increasing demands on resources (natural or
otherwise) that are, or are likely to become, in short
supply (e.g. demand on water use).
OTHER ENVIRONMENTAL ISSUES
Any cumulative environmental effect with other
existing or likely future activities (e.g. context within
electricity grid).
Minor
If ticked,
go to
next
issue.
OR
OTHER
NOTE: Projects with any HIGH Environmental Scores (>10) must be referred to the
Appropriate Officer at Country Energy.
FORM ENVIRONMENTAL ASSESSMENT IMPACT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 10 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
TABLE 4A OTHER RELEVANT COUNTRY ENERGY POLICIES/GUIDELINES
RELEVANT POLICY/GUIDELINE: Is the policy
relevant?
Has the policy
been considered?
CECP1023 Environment Policy Yes, No Yes, No
CECG1000 Safety, Health and Environmental Management Yes, No Yes, No
CEFD6139 Transfer of Responsibility for Second Hand Poles Yes, No Yes, No
CEFD6480 Initial Site Visit Checklist for Contamination Assessment Yes, No Yes, No
CEPG8008 Vegetation Management Plan Yes, No Yes, No
CEPG8013 PCB Identification and Management Yes, No Yes, No
CEPG8033 Electric and Magnetic Fields (Extra Low Frequency) Yes, No Yes, No
CEPG8052 Waste Management Yes, No Yes, No
CEM7063 Information Security Sensitivity Labelling and Handling Yes, No Yes, No
CEPG1078 Aboriginal Cultural Heritage (Draft document) Yes, No Yes, No
CEPG1096 Information Security Sensitivity Labelling and Handling Yes, No Yes, No
CEPG2016 Environmental Impact Assessment Yes, No Yes, No
CEPG2033 Management of Acid Sulphate Soils Yes, No Yes, No
CEPG2043 Minor Works on Asbestos Based Electrical Mounting
Boards for Domestic and Commercial Metering/Electrical Installations
Yes, No Yes, No
CEPG5041 Project Safety and Environment Plan Yes, No Yes, No
Other relevant policies/guidelines
Yes, No Yes, No
Yes, No Yes, No
Yes, No Yes, No
Yes, No Yes, No
NOTE: The Determining Officer must consider those Country Energy policies identified
in Table 4A of
CEFD6024 that are relevant to the project. These policies may contain additional Control
Measures to
mitigate the Environmental Impacts of the project or additional requirements relating to
how specific
activities that are part of the project must be conducted. If there is a particular issue for
which Country
Energy does not have a policy, an Appropriate Officer within Country Energy should be
consulted.
NOTE: Refer to sections 5A, 111 and 112 of the EPA Act, clause 228 of the EPA
Regulation, DoPs
guidelines Is an EIS required? and DECs Interim Community Guidelines for
Community Consultation
for a full list of the matters that must be taken into account to determine the likely impact
of an activity on
the environment. The relevant documents can be found online at the following locations:
1 EP&A Act and EP&A Regulation:
www.legislation.nsw.gov.au/maintop/scanact/inforce/NONE/0
2 DoPs guidelines Is an EIS required?:
www.planning.nsw.gov.au/assessingdev/pdf/gu_isaneisrequired.pdf
3 DECs Interim Community Guidelines for Community Consultation:
www.nationalparks.nsw.gov.au/PDFs/interim_consulation_guidelines.pdf
NOTE: Refer to CEPG2295 and CEPG2016 for a summary of these matters.
FORM ENVIRONMENTAL ASSESSMENT IMPACT CHECKLIST
CE-IN-CONFIDENCE CEFD6024
14 November 2006 Issue 4 Approved By: Chief Safety Officer Page 11 of 11
CE-IN-CONFIDENCE UNCONTROLLED COPY IF PRINTED
TABLE 5 DECISION AND SIGN OFF
Determining Officer Person who prepares and verifies the EIA
I certify to the best of my knowledge that:
I have completed this worksheet in accordance with CEPG2295 and CEPG2016, and
The assessment meets the requirements of sections 5A, 111 and 112 of the EP&A
Act, clause
228 of the EP&A Regulation and other relevant legislation and guidelines discussed in
CEPG2295 and CEPG2016, and
The information contained in the worksheet is not materially misleading, and
The project has minor and predictable impacts and can proceed subject to the
requirements in
CEPG2295, CEPG2016, generic control measures outlined in CEPG5041 and any
Project
Specific Control Measures if required (set out in Table 4), and
The worksheet has been referred to the relevant Country Energy officer if:
There are HIGH community impacts TABLE 1
There are any approvals, licences or permits in Trigger Areas TABLE 2
There are any Sensitive Area Trigger Areas TABLE 3
 There are any HIGH Environmental Scores (rating>10) TABLE 4
I certify on behalf of Country Energy that:
My assessment has been adequately completed, and
My conclusion as to the likely environmental impact of the project is reasonable.
NOTE: A site visit may be required depending on level of confidence and risk to the
environment.
Signature Date
Name Company Country Energy
STEPS 11- 12