Contractor Site Use Request Identification and Evaluation
Project No.:
Control No(s).:
Project Name:
County(s):

NOTE: This form is to be used for all Borrow/Plant/Stockpile/Waste and Construction Debris Site Requests. Site Requests will not be forwarded for Agency Review until all request requirements have been fulfilled by the Requestor. To avoid delay, please provide complete, clear and concise documentation and photographs.

Site Location and Ownership

1.	Identify the precise location of the site (to the nearest 2½ acres)

¼, of	¼,	of Section	T-	- N,	R-	–

a.	Attach a color aerial photo precisely depicting the site location, exact site boundaries, and haul roads.
b.	Attach color photographs, taken from the corners of the site inward that provide an accurate depiction of existing site characteristics (minimum of 4).

2.	Name of Owner:
a.	Address:
b.	Phone No.:
c.	Email Address:

Site Requestor

3.	Requesting Contractor:
a.	Address:
b.	Contact Person:
c.	Phone No.:
d.	Email Address:

4.	This site will be used for (Check all that apply):	Borrow	Plant	Stockpile	Waste
Construction Debris
Explanation:

5.	To your knowledge, has this site been previously used as a Borrow, Plant, Stockpile, Waste, or Construction Debris Site?
Yes	No	Unknown

NDOT Form 119, March 2020

6.	This site is currently used for:
Commercial Material Site	Borrow	Agriculture	Irrigation Recharge Pit
Stockpiled Materials	Pasture	Stock Pond	Urban/Suburban Residential
Other (explain)
Explanation:

7.	Vegetation cover (if applicable) is:

Grass	Type:
Trees	Type:
Weeds	Type:
Crops	Type:
None	Type:
Other (explain)

8.	Will any trees be removed that are 3 inches or greater diameter @ breast height (48 inches above ground
level)?	Yes	No

9.	Does this site currently pond water?	Yes	No
If Yes, give existing surface area of water:	Acres

10.	Will this site pond water when completed?
No	This site will be graded to prevent storage of surface water.
Yes	(If Yes, how many acre-feet will be exposed?	Acre-Feet

11.	Is this site within the Platte River System?	Yes	No
Refer to the attached Platte River System Reference Map
a.	Give depth of ponding area when	Feet
b.	Give maximum anticipated surface area of water when completed:	Acres
c.	Will the site detain water in excess of 72 hours?	Yes	No

SUBMIT TO:

Nebraska Department of Transportation ● Environmental Section ● PO Box 94759 ●

Lincoln NE 68509-4759 ● Email: ndot.mssrequest@nebraska.gov