Broadband Canada: Connecting Rural Canadians

Environmental Assessment Checklist

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Complete and return the form to:

Broadband Canada Program
Industry Canada
300 Slater Street, Room 20th Floor
Ottawa, Ontario
K1A 0C8

Fascimile: 613-949-1586

1. Project Information

Name of Applicant:

Project Title:

GSA:

Project Description:

Attach as a separate document a comprehensive description of the entire project, which should include:

  • All components of the project, including information related to the project's dimensions, distance from water, if the project area is on a serviced lot or not, etc.;
  • Size of buildings, antennas, towers, roads, and planned uses;
  • List of all stakeholders (if any) involved in the project (other federal departments/agencies, provincial, municipal etc.);
  • Location of project (include map of the project area);
  • Description of the environmental components on and surrounding the project site as well as surrounding areas (forest, fields, creeks, streams, wetlands, undeveloped, residential areas, industrial areas, environmentally sensitive areas, recognized or protected area, National Park, etc.); and
  • Project phases and timelines, with the anticipated start and end date of the project.

2.0 Is it a Project as defined by CEAA?

A project under CEAA is defined as "in relation to a physical work, any proposed construction (including renovation and expansion), operation, modification, decommissioning, abandonment or other undertaking". Examples include construction or installation of a radiocommunication antenna and its supporting structure, installation of new or expansion of existing fibre optic, coaxial cable or twisted copper pair wire lines, modifications to the interior of a building, etc. Some physical activities not specifically related to a physical work and prescribed under the CEAA Inclusion List Regulation may require an assessment. An example includes the remediation of contaminated land in Canada etc. The purchase of supplies or special equipment would not be considered a project under CEAA.

Yes No N/A

If you answer Yes above, continue with Question 3. If you answer No, please skip to Question 4.

3.0 Is the Project Excluded?

3.1 The proposed construction, installation, operation, expansion or modification of a radiocommunication antenna and its supporting structure

  1. Will the antenna and supporting structure be affixed to a building or located entirely within 15 m of a building?

    Yes No N/A

  2. Will the antenna, its supporting structure, or any of its supporting lines have a footprint greater than 25 m2?

    Yes No N/A

  3. Will the project be carried out within 30 m of a water body?

    Yes No N/A

  4. Will the project potentially result in the release of polluting substances into a body of water?

    Yes No N/A

3.2 The proposed construction, installation, operation, expansion or modification of a radiocommunication antenna and its supporting structure that is within 30m of a water body

  1. Will the antenna and supporting structure be affixed to a building?

    Yes No N/A

  2. Does the project result in an antenna with a height greater than 5 m and a height greater than 25% of the building to which it is affixed?; and

    Yes No N/A

  3. Will the project involve the likely release of a polluting substance into a water body?

    Yes No N/A

3.3 The proposed construction, installation, operation, expansion or modification of a radiocommunication antenna and its supporting structure that are affixed to a physical work other than a building

  1. Result in an antenna with a height greater than 5 m and a height greater than 25% of the height of the physical work to which it is affixed; and

    Yes No N/A

  2. Will the project involve the likely release of a polluting substance into a water body?

    Yes No N/A

3.4

  1. Will the proposed construction, installation, operation, modification, abandonment or replacement of a water pipe, a sewer or drain, a steam line or tunnel, or a buried telecommunication or electrical power line be located alongside or underneath a railway or road?

    Yes No N/A

  2. Will the project be carried out within 30 m of a water body?

    Yes No N/A

  3. Will the project involve the likely release of a polluting substance into a water body, or result in an increase in airborne emissions or noise during the operation of the physical work?

    Yes No N/A

3.5 The proposed construction, installation, operation, expansion or modification of a sidewalk, a boardwalk, a path, a pedestrian ramp or an access road

  1. Will the project be taking place on a serviced1 building lot?

    Yes No N/A

  2. If the project is on unserviced land, will the project affect the permafrost?

    Yes No N/A

  3. If the project in on unserviced land, will the project result in a physical work with a length in the case of construction or installation greater than 100 m?

    Yes No N/A

  4. If the project in on unserviced land, will the project result in a physical work with a length in the case of an expansion greater than 100 m and a length greater than 10% of the physical work?

    Yes No N/A

  5. Will the project be carried out within 30 m of a water body?

    Yes No N/A

  6. Will the project potentially result in the release of polluting substances into a body of water?

    Yes No N/A

3.6

  1. Will the proposed construction, installation, operation, expansion, modification or removal of a fence prevent the passage of wild animals?

    Yes No N/A

  2. Will the project be carried out within 30 m of a water body?

    Yes No N/A

  3. Will the project potentially result in the release of polluting substances into a body of water?

    Yes No N/A

3.7 The proposed construction, installation, operation or modification of a building

  1. Will the project result in a building footprint greater than 100 m2 or a height greater than 5m?

    Yes No N/A

  2. Will the proposed expansion of a building result in a building with a footprint greater than 100m2 and a footprint that is 10% larger than its current footprint?

    Yes No N/A

  3. Will the proposed expansion of a building result in a building with a height greater than 5m and a height that is 10% more than its current height?

    Yes No N/A

  4. Will the project be carried out within 30 m of a water body?

    Yes No N/A

  5. Will the project potentially result in the release of polluting substances into a body of water?

    Yes No N/A

4.0 Will the project take place in the following locations?

  1. Will the project take place in a National Park, National Park Reserve, National Historic Site or Historic Canal?

    Yes No N/A

  2. Will the project take place on a First Nation Reserve?

    Yes No N/A

5. Declaration

If your project does not fall into any of the above categories, please refer to the Canadian Environmental Assessment Exclusion List and Inclusion List Regulations for more information.

I certify that the above information is correct, complete and a full disclosure of the facts.

Name
_____________________________________

Title
_____________________________________

Signature
_____________________________________

Date
_________________________


1 "Serviced" in relation to a building lot, means equipped with hook-ups to water and sewage mains for water supply and for sewage disposal by way of a centralized municipal or community sewer and water system. (Back to text)