Fillable Printable Union Pacific Application Form

Union Pacific Application Form

APPLICATION FORM FOR UNION PACIFIC RAILROAD COMPANY

ENVIRONMENTAL RIGHT OF ENTRY AGREEMENT

Please fill in as indicated. Please type or print clearly in all capital letters:

RESPONSIBLE PARTY / LICENSEE:

Company Name__________________________________________________________________

P O Box & Street Address______ ____________________________________________________

City, State, Zip Code______________________________________________________________

State of Incorporation________________________________________ _____________________

Contact: (Name / Title)__________________ ___________________________ _______________

(Phone / Fax)_____________________________________________________________

(email, if possible)________________________________________________________

LICENSEE CONSULTANT (if applicable)

Company Name__________________________________________________________________

P O Box & Street Address______ ____________________________________________________

City, State, Zip Code______________________________________________________________

Contact: (Name / Title)__________________ ___________________________ _______________

(Phone / Fax)_____________________________________________________________

(email, if possible)________________________________________________________

SITE LOCATION (include City / County / State)______________________________________________

RAILROAD MILEPOST AND SUBDIVISION_______________________________________________

(or DOT Crossing Number on nearest railroad/street crossing)

LATITUDE AND LONGITUDE (degrees/minutes/seconds)__________________________________________

ADVISE THE NAME , AD D RESS, & C ON TACT PERS O N OF THE GO VERNM E NT AL AG ENCY

REQUIRING THIS PROJECT:

______________________________________________________________________________________

Please describe your proposed project:

PROJECT LEVEL(S):

_________ PHASE I (Non-invasi ve & no n-intrusive visual sit e ins pection and records check o nly .

No sampling will be involved.)

_________ PHASE II (Site investigation. You must advise specific testing to be performed from the

list on the next page.)

_________ PHASE III (Site remediation.)

_________ OTHER (Please describe your project in detail only as it pertains to railroad property)

TERM: DATES

From:__________To :____________(Includes removal/lawful closure of facilities and/or monitoring wells)

TYPE OF ENVIRONMENTAL TESTING NUMBER OF EACH

Subsurface Soil/Sediment Samples __________________

Hand Held Auger Borings __________________

Soil Gas Survey Points __________________

Boring Drilled w/Soil Samples __________________

Temporary Piezometer Wells __________________

Temporary Monitor Wells (must

be flush-mounted) __________________

Permanent Monitoring Wells __________________

Recovery Wells & Associated abov e Gro und Equipment _____________ _____

Recovery Systems & Above Ground Equipmen t _____________ _____

Other (Describe fully)_______________________________ ____________________________________

SPECIAL PROVISIONS:

_______CONFIDENTIALITY (Required for all cases involving sale of Railroad property & in many other cases.)

_______RAILROAD FLAGMAN (Required in all Phase II/III cases & many other cases.)

_______MONITORING WELL (Required for all monitor wells & piezometers.)

_______FURNISH INFORMATION (Required in all cases.)

_______PROOF OF FINANCIAL CAPABILITY OR PERFORMANCE BOND (Required for all monitor wells,

piezometers, & other facilities.)

CONTRACTOR INFORMATION:

(Must be copied for all contractors that will work under this agreemen t)

NAME OF CONTRACTOR__________________________________________________ ____________________

INCORPORATED IN WHAT STATE______________________________________________________________

FULL MAILING ADDRESS_______________________________________ ___________________________ ___

_______________________________________________________________________________

NAME & TITLE OF CONTRACTOR CONTACT PERSON___________________________________________

_______________________________________________________________________________

CONTRACTOR TELEPHONE NUMBER__________________________________________________________

CONTRACTOR FAX NUMBER_______________ ___________________________ ________________________

EMAIL ADDRESS________________________________ ___________________________ __________________

( ) COMPLETE AND RETURN THIS APPLICATION FORM, with

( ) A $555.00 CHECK (Payable to Union Pacific Railroad Company), and

( ) THE OTHER REQUESTED MATERIAL ON THE CHECKLIST

to the appropriate Environmental Access Manager.

NOTE

: Other fees and charges may be applicable to your request. These charges cannot be determined until your

Project is approved.