HomeMy Public PortalAboutRES-CC-2006-15Resolution #15-2006
A RESOLUTION APPROVING THE ASSIGNMENT OF A BUREAU OF LAND
MANAGEMENT RIGHT OF WAY LEASE TO THE CITY OF MOAB
WHEREAS, the proposed Allen and Sunrise Hills Subdivisions are located adjacent to one
another; and
WHEREAS, said subdivisions will require at least two accesses; and
WHEREAS, a condition of approval of the subdivisions is construction of a rockfall hazard
mitigation and drainage berm; and
WHEREAS, the boundaries of public and private lands are situated such that in order for the
development of said subdivisions to proceed, a Right of Way Grant was given by the Bureau
of Land Management to the property owners of the property slated for said subdivisions to
accommodate segments of a road and a rockfall mitigation and drainage berm; and
WHEREAS, said Right of Way Grant should be assigned to the City to provide for the
maintenance of the road and rockfall mitigation and drainage berm; and
WHEREAS, the Bureau of Land Management has stipulated an application and process for
the assignment of said Right of Way Grant to the City; and
WHEREAS, said assignment of Right of Way Grant would be granted in perpetuity at no
cost to the City; and
WHEREAS, the original Right of Way Grant and the Application for Assignment of said
Right of Way Grant are attached to this resolution.
NOW THEREFORE, WE THE GOVERNING BODY of the City of Moab do hereby
approve the assignment of the attached Right of Way Grant from Charles Pipkin and Dwight
Johnston to the City of Moab and do hereby authorize the appropriate officials to submit the
appropriate applications and execute the necessary documents to consummate the
assignment.
PASSED AND APPROVED in open Council by a majority vote of the Governing Body of
Moab City Council on May 9, 2006
Rachel Ellison, Recorder
David L. Sakrison, Mayor
Resolution #15-2006
Page 1 of 1
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STANDARD FORM 299 (2/2003)
Prescribed by DOWSDA/DOT
P.L. 96-487 and Federal
Register Notice 5-22-95
APPLICATION FOR TRANSPORTATION AND
UTILITY SYSTEMS AND FACILITIES
ON FEDERAL LANDS
FORM APPROVED
OMB NO. 1004-0189
Expires: October 31, 2005
FOR AGENCY USE ONLY
NOTE: Before completing and filing the application, the applicant should completely review this package and schedule a
preapplication meeting with representatives of the agency responsible for processing the application. Each agency
may have specific and unique requirements to be met in preparing and processing the application. Many times, with
the help of the agency representative, the application can be completed at the preapplication meeting.
Application Number
Date filed
1. Name and address of applicant (include zip code)
-_.-
#,, Sfg53-2-
2. Name, title, and address of authorized agent if different
from Item 1 (include zip code)
Arai
3. TELEPHONE (area code)
Applicant
Authorized Agent
4. As applicant are you? (check one)
a. ❑ Individual
b. ❑ Corporation*
c. ❑ Partnership/Association*
d. ❑ State Govemment/State Agency
e. Local Govemment
f. ❑ Federal Agency
* If checked, complete supplemental page
5. Specify what application is for: (check one)
a. ❑ New authorization
b. ❑ Renewing existing authorization No.
c. ❑ Amend existing authorization No.
d., Assign existing authorization No.
e. ❑ Existing use for which no authorization has been received*
f. ❑ Other*
* If checked, provide details under Item 7
6. If an individual, or partnership are you a citizen(s) of the United States? ❑ Yes ❑ No
7. Project description (describe in detail): (a) Type of system or facility, (e.g., cat:al, pipeline, road); (b) related structures and facilities; (c) physical specifications
(length, width, grading, etc.); (d) term of years needed; (e) time of year of use or operation; (f) Volume or amount of product to be transported; (g) duration and
timing of construction; and (h) temporary work areas needed for construction (Attach additional sheets, if additional space is needed.)
/move- G zeL4 6 4 -1 444d _' v ut_e_ - criwl fr+a-
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8. Attach a map covering area and show location of project proposal
9. State or local government approval: ❑ Attached ❑ Applied for ❑ Not required
10. Nonreturnable application fee: ❑ Attached ❑ Not required
11. Does project cross intemational boundary or affect intemational waterways? ❑ Yes ❑ No (If "yes," indicate on Wrap)
12. Give statement of your technical and financial capability to construct, operate, maintain, and terminate system for which authorization is being requested.
(Continued on page 2) This form is authorized for local reproduction.
13a. Describe other reasonable alternative routes and modes considered.
b. Why were these alternatives not selected?
c. Give explanation as to why it is necessary to cross Federal Lands.
14. List authorizations and pending applications filed for similar projects which may provide information to the authorizing agency. (Specify number, date, code, or name)
15. Provide statement of need for project, including the economic feasibility and items such as: (a) cost of proposal (construction, operation, and maintenance); (b)
estimated cost of next best alternative; and (c) expected public benefits.
16. Describe probable effects on the population in the area, including the social and economic aspects, and the rural lifestyles.
17. Describe likely environmental effects that the proposed project will have on: (a) air quality; (b) visual impact; (c) surface and ground water quality and quantity; (d)
the control or structural change on any stream or other body of water; (e) existing noise levels; and (f) the surface of the land, including vegetation, permafrost, soil,
and soil stability.
18. Describe the probable effects that the proposed project will have on (a) populations of fish, plantlife, wildlife, and marine life, including threatened and endangered
species; and (b) marine mammals, including hunting, capturing, collecting, or killing these animals.
19. State whether any hazardous material, as defined in this paragraph, will be used, produced, transported or stored on or within the right-of-way or any of the right-of-way
facilities, or used in the construction, operation, maintenance or termination of the right-of-way or any of its facilities. "Hazardous material" means any substance,
pollutant or contaminant that is listed as hazardous under the Comprehensive Environmental Response, Compensation, and Liability Act of 1980, as amended, 42 U.S.C.
9601 et seq., and its regulations. The definition of hazardous substances under CERCLA includes any "hazardous waste" as defined in the Resource Conservation and
Recovery Act of 1976 (RCRA), as amended, 42 U.S.C. 9601 et seq., and its regulations. The term hazardous materials also includes any nuclear or byproduct material
as defined by the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011 et seq. The term does not include petroleum, including crude oil or any fraction thereof that
is not otherwise specifically listed or designated as a hazardous substance under CERCLA Section 101(14), 42 U.S.C. 9601(14), nor does the term include natural gas.
20. Name all the Department(s)/Agency(ies) where this application is being filed.
I HEREBY CERTIFY, That I am of legal age and authorized to do business in the State and that I have personally examined the information contained in the application and
believe that the information submitted is correct to the best of my knowledge.
,Signature of Applicant Date
Title 18, U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the United
States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page 3)
SF-299, page 2
APPLICATION FOR TRANSPORTATION AND UTILITY SYSTEMS
AND FACILITIES ON FEDERAL LANDS
GENERAL INFORMATION
ALASKA NATIONAL INTEREST LANDS
This application will be used when applying for a right-of-way, permit,
license, lease, or certificate for the use of Federal lands which lie within
conservation system units and National Recreation or Conservation Areas
as defined in the Alaska National Interest Lands Conservation Act.
Conservation system units include the National Park System, National
Wildlife Refuge System, National Wild and Scenic Rivers System,
National Trails System, National Wilderness Preservation System, and
National Forest Monuments.
Transportation and utility systems and facility uses for which the
application may be used are:
1. Canals, ditches, flumes, laterals, pipes, pipelines, tunnels, and other
systems for the transportation of water.
2. Pipelines and other systems for the transportation of liquids other than
water, including oil, natural gas, synthetic liquid and gaseous fuels,
and any refined product produced therefrom.
3. Pipelines, slurry and emulsion systems, and conveyor belts for
transportation of solid materials.
4. Systems for the transmission and distribution of electric energy.
5. Systems for transmission or reception of radio, television, telephone,
telegraph, and other electronic signals, and other means of
communications.
6. Improved rights -of -way for snow machines, air cushion vehicles, and
all -terrain vehicles.
7. Roads, highways, railroads, tunnels, tramways, airports, landing
strips, docks, and other systems of general transportation.
This application must be filed simultaneously with each Federal
department or agency requiring authorization to establish and operate
your proposal.
In Alaska, the following agencies will help the applicant file an
application and identify the other agencies the applicant should contact
and possibly file with:
Department of Agriculture
Regional Forester, Forest Service (USFS)
Federal Office Building, P.O. Box 21628
Juneau, Alaska 99802-1628
Telephone: (907) 586-7847 (or a local Forest Service Office)
Department of the Interior
Bureau of Indian Affairs (BIA)
Juneau Area Office
9109 Mendenhall Mall Road, Suite 5, Federal Building Annex
Juneau, Alaska 99802
Telephone: (907) 586-7177
Bureau of Land Management (BLM)
222 West 7th Ave., Box 13
Anchorage, Alaska 99513-7599
Telephone: (907) 271-5477 (or a local BLM Office)
National Park Service (NPS)
Alaska Regional Office, 2525 Gambell St., Rm. 107
Anchorage, Alaska 99503-2892
Telephone: (907) 257-2585
U.S. Fish & Wildlife Service (FWS)
Office of the Regional Director
1011 East Tudor Road
Anchorage, Alaska 99503
Telephone: (907) 786-3440
Note -Filings with any Interior agency may be filed with any office noted
above or with the: Office of the Secretary of the Interior, Regional
Environmental Officer, Box 120, 1675 C Street, Anchorage, Alaska
99513.
Department of Transportation
Federal Aviation Administration
Alaska Region AAL-4, 222 West 7th Ave., Box 14
Anchorage, Alaska 99513-7587
Telephone: (907) 271-5285
NOTE - The Department of Transportation has established the above
central filing point for agencies within that Department. Affected
agencies are: Federal Aviation Administration (FAA), Coast Guard
(USCG), Federal Highway Administration (FHWA), Federal Railroad
Administration (FRA).
OTHER THAN ALASKA NATIONAL INTEREST LANDS
Use of this form is not limited to National Interest Conservation Lands of
Alaska.
Individual departments/agencies may authorize the use of this form by
applicants for transportation and utility systems and facilities on other
Federal lands outside those areas described above.
For proposals located outside of Alaska, applications will be filed at the
local agency office or at a location specified by the responsible Federal
agency.
SPECIFIC INSTRUCTIONS
(Items not listed are self-explanatory)
Item
7 Attach preliminary site and facility construction plans. The
responsible agency will provide instructions whenever specific
plans are required.
8 Generally, the map must show the section(s), township(s), and
range(s) within which the project is to be located. Show the
proposed location of the project on the map as accurately as
possible. Some agencies require detailed survey maps. The
responsible agency will provide additional instructions.
9, 10, and 12 - The responsible agency will provide additional
instructions.
13 Providing information on alternate routes and modes in as much
detail as possible, discussing why certain routes or modes were
rejected and why it is necessary to cross Federal lands will assist
the agency(ies) in processing your application and reaching a
final decision. Include only reasonable alternate routes and
modes as related to current technology and economics.
14 The responsible agency will provide instructions.
15 Generally, a simple statement of the purpose of the proposal will
be sufficient. However, major proposals located in critical or
sensitive areas may require a full analysis with additional specific
information. The responsible agency will provide additional
instructions.
16 through 19 - Providing this information in as much detail as
possible will assist the Federal agency(ies) in processing the
application and reaching a decision. When completing these
items, you should use a sound judgment in furnishing relevant
information. For example, if the project is not near a stream or
other body of water, do not address this subject. The responsible
agency will provide additional instructions.
Application must be signed by the applicant or applicant's
authorized representative.
If additional space is needed to complete any item, please put the
information on a separate sheet of paper and identify it as
"Continuation of Item".
(For supplemental, see page 4)
SF-299, page 3
SUPPLEMENTAL
NOTE: The responsible agency(ies) will provide additional instructions
CHECK APPROPRIATE
BLOCK
I - PRIVATE CORPORATIONS
ATTACHED
FILED*
a. Articles of IncorporationLi
U
b. Corporation Bylaws
c. A certification from the State showing the corporation is in good standing and is entitled to operate within the State.
.
d. Copy of resolution authorizing filingI:1
CI
e. The name and address of each shareholder owning 3 percent or more of the shares, together with the number and percentage of any
class of voting shares of the entity which such shareholder is authorized to vote and the name and address of each affiliate of the entity
together with, in the case of an affiliate controlled by the entity, the number of shares and the percentage of any class of voting stock of
that affiliate owned, directly or indirectly, by that entity, and in the case of an affiliate which controls that entity, the number of shares
and the percentage of any class of voting stock of that entity owned, directly or indirectly, by the affiliate.
❑
❑
f. If application is for an oil or gas pipeline, describe any related right-of-way or temporary use permit applications, and identify
previous applications.
Ul
Zit
g. If application is for an oil and gas pipeline, identify all Federal lands by agency impacted by proposal.
❑
❑
II - PUBLIC CORPORATIONS
a. Copy of law forming corporation
❑
❑
b. Proof of organization
❑
❑
c. Copy of Bylaws
❑
❑
d. Copy of resolution authorizing filing
e. If application is for an oil or gas pipeline, provide information required by Item "I-f" and "I-g" above.
❑
❑
III - PARTNERSHIP OR OTHER UNINCORPORATED ENTITY
a. Articles of association, if any
❑
LI
b. If one partner is authorized to sign, resolution authorizing action is
❑
❑
c. Name and address of each participant, partner, association, or other
❑
❑
d. If application is for an oil or gas pipeline, provide information required by Item "I-f' and "I-g" above.
* If the required information is already filed with the agency processing this application and is current, check block entitled "Filed.' Provide the file identification
information (e.g., number, date, code, name). If not on file or current, attach the requested information.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The Federal agencies collect this information from applicants requesting right-of-
way, permit, License, lease, or certifications for the use of Federal lands.
Federal agencies use this information to evaluate your proposal.
No Federal agency may request or sponsor, and you are not required to respond to
a request for information which does not contain a currently valid OMB Control
Number.
BURDEN HOURS STATEMENT
The public burden for this form is estimated at 25 hours per response including
the time for reviewing instructions, gathering and maintaining data, and
completing and reviewing the form. Direct comments regarding the burden
estimate or any other aspect of this form to: U.S. Department of the Interior,
Bureau of Land Management (1004-0189), Bureau Information Collection
Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401LS,
Washington, D.C. 20240
A reproducible copy of this form may be obtained from the Bureau of Land
Management, Land and Realty Group, 1620 L Street, N.W., Rm. 1000LS,
Washington, D.C. 20036.
(Continued on page 5)
SF-299, page 4
NOTICE
NOTE: This applies to the Department of the InteriorBureau of Land Management (BLM).
The Privacy Act of 1974 provides that you be furnished with the following information in
connection with the information provided by this application for an authorization.
AUTHORITY: 16 U.S.C. 310 and 5 U.S.C. 301.
PRINCIPAL PURPOSE: The primary uses of the records are to facilitate the (1) processing
of claims or applications; (2) recordation of adjudicative actions; and (3) indexing of
documentation in case files supporting administrative actions.
ROUTINE USES: BLM and the Department of the Interior (DOI) may disclose your
information on this form: (1) to appropriate Federal agencies when concurrence or supporting
information is required prior to granting or acquiring a right or interest in lands or resources;
(2) to members or the public who have a need for the information that is maintained by BLM
for public record; (3) to the U.S. Department of Justice, court, or other adjudicative body when
DOI determines the information is necessary and relevant to litigation; (4) to appropriate
Federal, State, local, or foreign agencies responsible for investigating, prosecuting violation,
enforcing, or implementing this statute, regulation, or order; and (5) to a congressional office
when you request the assistance of the Member of Congress in writing.
EFFECT OF NOT PROVIDING THE INFORMATION: Disclosing this information is
necessary to receive or maintain a benefit. Not disclosing it may result in rejecting the application.
SF-299, page 5
"
A l
FORM 2800-14
(August 1985)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
RIGHT-OF-WAY GRANT
SERIAL NUMBER UTU-82642
Issuing Office
Moab Field Office
1. A right-of-way is hereby granted pursuant to Title V of the Federal Land Policy and
Management Act of October 21, 1976 (90 Stat. 2776; 43 U.S.C. 1761).
2. Nature of Interest:
a. By this instrument, the holders
Charles Pipkin
3380 Redcliff Road
Moabl, Utah 84532
Dwight Johnston
927 26 Road
Grand Junction, CO 81506
receive a right to construct, use, maintain, and terminate the facilities described below on
public lands described as follows:
T. 26 S., R. 21 E., SLM.
sec.12, within lots 2 and 4, totaling 1.19 acres, more or less.
(1) Two segments of access road 50 feet in width, from gutter to gutter, and a drainage
control berm west of the road.
80 feet wide and 195 feet long within lot 2 (connecting the Sunrise Hills and Allen
Subdivisions);
80 feet wide and 300 feet long within lot 4 (connecting 2 sections of the Allen
Subdivision);
totaling 1.05 acre:
(2) Three 100-foot long berm segments, at the ends of the berm on private land. One
segment is in lot 2 and two segments are in lot 4.
20 feet wide and 300 feet long, totaling 0.14 acre.
b. This instrument shall terminate on December 31, 2034 unless, prior thereto, it is
relinquished, abandoned, terminated, or modified pursuant to the terms and conditions of
this instrument or of any applicable Federal law or regulation.
c. This instrument may be renewed. If renewed, the right-of-way shall be subject to the
regulations existing at the time of renewal and any other terms and conditions that the
authorized officer deems necessary to protect the public interest.
-2-
d. Notwithstanding the expiration of this instrument or any renewal thereof, early
relinquishment, abandonment, or termination, the provisions of this instrument, to the
extent applicable, shall continue in effect and shall be binding on the holder, its
successors, or assigns, until they have fully satisfied the obligations and/or liabilities
accruing herein before or on account of the expiration, or prior termination, of the grant.
3. Rental:
For and in consideration of the rights granted, the holder agrees to pay the Bureau of Land
Management fair market value rental as determined by the authorized officer unless
specifically exempted from such payment by regulation. Provided, however, that the rental
may be adjusted by the authorized officer, whenever necessary, to reflect changes in the fair
market rental value as determined by the application of sound business management
principles, and so far as practicable and feasible, in accordance with comparable commercial
practices.
Based on the linear RNV rental schedule, the rental fee is $83.84 for the period of November
2005 through December 31, 2014. Future rental payments will be payable in advance for 10-
year terms and will be requested by computer billing.
4. Terms and Conditions:
a. This grant is issued subject to the holder's compliance with all applicable regulations
contained in Title 43 Code of Federal Regulations part 2800.
b. The right-of-way is issued subject to prior valid existing rights, including the following
rights -of -way UTUO-15664 (Williams buried pipeline, 50' width), UTU-43521 (Mid -
America buried pipeline, 50' width), UTU-10657 (345 kV aerial powerline, 130' width)
and UTUO-35443 (130 kV aerial powerline, 100' width).
c. The holder shall provide a bond or other security satisfactory to the authorized officer,
in the amount of $5,000, to be maintained until the subdivisions have been constructed
and the project on BLM lands has been accepted by the authorized officer. Upon
completion of these construction related requirements, the authorized officer may
terminate the bond or security.
d. Construction on public lands is not authorized until the subdivisions have been
approved by the City of Moab. The holder will notify the BLM at least 48 hours prior to
construction. The contact person is Mary von Koch 435-259-2128.
e. Each grant issued for a term of 20 years or more shall, at a minimum, be reviewed by
the authorized officer at the end of the 20th year and at regular intervals thereafter not
to exceed 10 years. Provided, however, that a right-of-way granted herein may be
reviewed at any time deemed necessary by the authorized officer.
f. The maps set forth in Exhibit A, attached hereto, are incorporated into and made a part
of this grant instrument.
g.
-3-
The berms constructed west of the road shall be constructed with native rock, not
exceeding six (6) feet in height. They will be seeded with native grass seed in the fall.
h. Failure of the holder to comply with applicable law or any provision of this right-of-way
grant shall constitute grounds for suspension or termination thereof.
The holder shall perform all operations in a good and workmanlike manner so as to
ensure protection of the environment and the health and safety of the public.
The holder shall conduct all activities associated with the operation, maintenance, and
termination of the right-of-way within the authorized limits of the right-of-way.
k. No construction or routine maintenance activities shall be performed during periods
when the soil is too wet to adequately support construction equipment. If such
equipment creates ruts in excess of six inches deep, the soil shall be deemed too wet
to adequately support construction equipment.
1. Any cultural and/or paleontological resources (historic or prehistoric site or object)
discovered by the holder, or any person working on his behalf, on public or Federal
land shall be immediately reported to the authorized officer. Holder shall suspend all
operations in the immediate area of such discovery until written authorization to
proceed is issued by the authorized officer. An evaluation of the discovery will be
made by the authorized officer to determine appropriate actions to prevent the loss of
significant cultural or scientific values. The holder will be responsible for the cost of
evaluation and any decision as to proper mitigation measures will be made by the
authorized officer after consulting with the holder.
m. All survey monuments, witness corners, reference monuments and bearing trees must
be protected against destruction. Any damaged or obliterated markers must be re-
established in accordance with accepted survey practices at the expense of the holder.
n. Upon relinquishment or termination of the right-of-way, the holder will remove surfacing
material (i.e. gravel, roadbase) and recontour disturbed areas, or designated sections
of the right-of-way, by grading to restore the site to approximately the original contour
of the ground as determined by the authorized officer.
o. The holder shall seed all disturbed areas, using an agreed upon method suitable for
the location. Seeding shall be repeated if a satisfactory stand is not obtained as
determined by the authorizing officer upon evaluation after the second growing season.
1/(
-4-
IN WITNESS WHEREOF, The undersigned agree to the terms and conditions of this right-of-way
grant.
ij///(
(Signature of H
(Title)
adt/C(C_
O /2V (25
(Date)
(Signature of - d
(Title)
`.€, //i)
(Signat a �•f BLM Aorized Officer)
Flad 444_fria_
(Title)
io /2 6 /o5
(Effective Date of Grant)
STANDARD FORM 299 (6/99)
Prescribed by DOI/USDA/DOT
P.L. 96-487 and Federal
Register Notice 5-22-95
APPLICATION FOR TRANSPORTATION AND
UTILITY SYSTEMS AND FACILITIES
ON FEDERAL LANDS
FORM APPROVED
OMB NO. 0596-0082
FOR AGENCY USE ONLY
NOTE: Before completing and filing the application, the applicant should completely review this package and
schedule a preapplication meeting with representatives of the agency responsible for processing the
application. Each agency may have specific and unique requirements to be met in preparing and proce-
ssing the application. Many times, with the help of the agency representative, the application can be
completed at the preapplication meeting.
Application Number
Date Filed
1. Name and address of applicant (include zip code)
2. Name, title, and address of authorized agent
if different from item 1 (include zip code)
3. Telephone (area code)
Applicant
Authorized Agent
4. As applicant are you? (check one)
a. Individual
b. Corporation*
c. Partnership/Association*
d. State Govemment/State Agency
e. Local Government
f. Federal Agency
* If checked, complete supplemental page
5. Specify what application is for: (check one)
a. New authorization
b. Renewing existing authorization No.
c. Amend existing authorization No.
d. Assign existing authorization No.
e. Existing use for which no authorization has been received *
f. Other*
* If checked, provide details under item 7
6. If an individual, or partnership are you a citizen(s) of the United States? _ Yes _ No
7. Project description (describe in detail): (a) Type of system or facility, (e.g., canal, pipeline, road); (b) related structures and facilities; (c) physical specifi-
cations (Length, width, grading, etc.); (d) term of years needed: (e) time of year of use or operation; (f) Volume or amount of product to be transported;
(g) duration and timing of construction; and (h) temporary work areas needed for construction (Attach additional sheets, if additional space is needed.)
8. Attach a map covering area and show location of project proposal
9. State or Local government approval:
Attached
Applied for Not Required
10. Nonretumable application fee: Attached
Not required
11. Does project cross international boundary or affect international waterways? Yes No (if 'yes," indicate on map)
12. Give statement of your technical and financial capability to construct, operate, maintain, and terminate system for which authorization is being requested.
(Continued on reverse) This form is authorized for local reproduction.
13a. Describe other reasonable alternative routes and modes considered.
b. Why were these alternatives not selected?
c. Give explanation as to why it is necessary to cross Federal Lands.
14. List authorizations and pending applications filed for similar projects which may provide information to the authorizing agency. (Specify number, date,
code, or name)
15. Provide statement of need for project, including the economic feasibility and items such as: (a) cost of proposal (construction, operation, and mainten-
ance); (b) estimated cost of next best alternative; and (c) expected public benefits.
16. Describe probable effects on the population in the area, including the social and economic aspects, and the rural lifestyles.
17. Describe likely environmental effects that the proposed project will have on: (a) air quality; (b) visual impact; (c) surface and ground water quality and
quantity; (d) the control or structural change on any stream or other body of water; (e) existing noise levels; and (f) the surface of the land, including
vegetation, permafrost, soil, and soil stability.
18. Describe the probable effects that the proposed project will have on (a) populations of fish, plantlife, wildlife, and marine life, including threatened and
endangered species; and (b) marine mammals, including hunting, capturing, collecting, or killing these animals.
19. State whether any hazardous material, as defined in this paragraph, will be used, produced, transported or stored on or within the right-of-way or any of
the right-of-way facilities, or used in the construction, operation, maintenance or termination of the right-of-way or any of its facilities. "Hazardous material"
means any substance, pollutant or contaminant that is listed as hazardous under the Comprehensive Environmental Response, Compensation, and Liability
Act of 1980, as amended, 42 U.S.C. 9601 et seq., and its regulations. The definition of hazardous substances under CERCLA includes any "hazardous waste"
as defined in the Resource Conservation and Recovery Act of 1976 (RCRA), as amended, 42 U.S.C. 6901 et seq., and its regulations. The term hazardous
materials also includes any nuclear or byproduct material as defined by the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011 et seq. The term does
not include petroleum, including crude oil or any fraction thereof that is not otherwise specifically listed or designated as a hazardous substance under CERCIA
Section 101(14), 42 U.S.C. 9601(14), nor does the term include natural gas.
20. Name all the Department(s)/Agency(ies) where this application is being filed.
I HEREBY CERTIFY, That I am of legal age and authorized to do business in the State and that I have personally examined the information contained in the
application and believe that the information submitted is correct to the best of my knowledge.
Signature of Applicant
Date
Title 18, U.S.C. Section 1001, makes it a crime for any persoh knowingly and w'Ilfully to make to any department or agency of the United States any false, ficti-
tious, or fraudulent statements or representations as to any matter within its jurisdiction.
APPLICATION FOR TRANSPORTATION AND UTILITY SYSTEMS
AND FACILITIES ON FEDERAL LANDS
GENERAL INFORMATION
ALASKA NATIONAL INTEREST LANDS
This application will be used when applying for a right-of-way, permit, license,
lease, or certificate for the use of Federal lands which lie within conservation
system units and National Recreation or Conservation Areas as defined in
the Alaska National Interest lands Conservation Act. Conservation system
units include the National Park System, National Wildlife Refuge System,
National Wild and Scenic Rivers System, National Trails System, National
Wilderness Preservation System, and National Forest Monuments.
Transportation and utility systems and facility uses for which the application
may be used are:
1. Canals, ditches, flumes, laterals, pipes, pipelines, tunnels, and other
systems for the transportation of water.
2. Pipelines and other systems for the transportation of liquids other than
water, including oil, natural gas, synthetic liquid and gaseous fuels, and any
refined product produced therefrom.
3. Pipelines, slurry and emulsion systems, and conveyor belts for tran-
sportation of solid materials.
4. Systems for the transmission and distribution of electric energy.
5. Systems for transmission or reception of radio, television, telephone,
telegraph, and other electronic signals, and other means of communications.
6. Improved right-of-way for snow machines, air cushion vehicles, and all -
terrain vehicles.
7. Roads, highways, railroads, tunnels, tramways, airports, landing strips,
docks, and other systems of general transportation.
This application must be filed simultaneously with each Federal department
or agency requiring authorization to establish and operate your proposal.
In Alaska, the following agencies will help the applicant file an application and
identify the other agencies the applicant should contact and possibly file with:
Department of Agriculture
Regional Forester, Forest Service (USFS)
Federal Office Building,
P.O. Box 21628
Juneau, Alaska 99802-1628
Telephone: (907) 586-7847 (or a local Forest Service Office)
Department of the Interior
Bureau of Indian Affairs (BIA)
Juneau Area Office
Federal Building Annex
9109 Mendenhall Mall Road, Suite 5
Juneau, Alaska 99802
Telephone: (907) 586-7177
Department of the Interior
Bureau of Land Management
222 West 7th Avenue
P.O. Box 13
Anchorage, Alaska 99513-7599
Telephone: (907) 271-5477 (or a local BLM Office)
National Park Service (NPS)
Alaska Regional Office
2525 Gambell Street, Room 107
Anchorage, Alaska 99503-2892
Telephone: (907) 257-2585
U.S. Fish & Wildlife Service (FWS)
Office of the Regional Director
1011 East Tudor Road
Anchorage, Alaska 99503
Telephone: (907) 786-3440
Note - Filings with any Interior agency may be filed with any office noted
above or with the Office of the Secretary of the Interior, Regional Envi-
ronmental Office,r P.O. Box 120, 1675 C Street, Anchorage, Alaska 99513.
Department of Transportation
Federal Aviation Administration
Alaska Region AAL-4, 222 West 7th Ave., Box 14
Anchorage, Alaska 99513-7587
Telephone: (907) 271-5285
NOTE - The Department of Transportation has established the above central
filing point for agencies within that Department. Affected agencies are:
Federal Aviation Administration (FAA), Coast Guard (USCG), Federal High-
way Administration (FHWA), Federal Railroad Administration (FRA).
OTHER THAN ALASKA NATIONAL INTEREST LANDS
Use of this form is not limited to National Interest Conservation Lands of
Alaska.
Individual department/agencies may authorize the use of this form by ap-
plicants for transportation and utility systems and facilities on other Federal
lands outside those areas described above.
For proposals located outside of Alaska, applications will be filed at the local
agency office or at a location specified by the responsible Federal agency.
SPECIFIC INSTRUCTIONS
(Items not listed are self-explanatory)
Item
7 Attach preliminary site and facility construction plans. The responsible
agency will provide instructions whenever specific plans are required.
8 Generally, the map must show the section(s), township(s), and range(s)
within which the project is to be located. Show the proposed location
of the project on the map as accurately as possible. Some agencies
require detailed survey maps. The responsible agency will provide
additional instructions.
9 10, and 12 - The responsible agency will provide additional instruc-
tions.
13 Providing information on alternate routes and modes in as much detail
as possible, discussing why certain routes or modes were rejected and
why it is necessary to cross Federal lands will assist the agency(ies) in
processing your application and reaching a final decision. Include only
reasonable alternate routes and modes as related to current tech-
nology and economics.
14 The responsible agency will provide instructions.
15 Generally, a simple statement of the purpose of the proposal will be
sufficient. However, major proposals located in critical or sensitive
areas may require a full analysis with additional specific information.
The responsible agency will provide additional instructions.
16 through 19 - Providing this information is as much detail as possible
will assist the Federal agency(ies) in processing the application and
reaching a decision. When completing these items, you should use a
sound judgment in furnishing relevant information. Fore example, if the
project is not near a stream or other body of water, do not address this
subject. The responsible agency will provide additional instructions.
Application must be signed by the applicant or applicant's authorized repres-
entative.
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is voluntary. If all the
information is not provided, the application may be rejected.
DATA COLLECTION STATEMENT
The Federal agencies collect this information from applicants requesting right-of-way, permit, license,
lease, or certification for the use of Federal lands.
The Federal agencies use this information to evaluate the applicant's proposal.
The public is obligated to submit this form if they wish to obtain permission to use Federal lands.
(For supplemental, see reverse)
SUPPLEMENTAL
NOTE: The responsible agency(ies) will provide instructions
CHECK APPROPRIATE
BLOCK
I - PRIVATE CORPORATIONS
ATTACHED
FILED*
a. Articles of Incorporation
b. Corporation Bylaws
c. A certification from the State showing the corporation is in good standing and is entitled to operate within the State
c. Copy of resolution authorizing filing
e. The name and address of each shareholder owning 3 percent or more of the shares, together with the number and
percentage of any class of voting shares of the entity which such shareholder is authorized to vote and the name and
address of each affiliate of the entity together with, in the case of an affiliate controlled by the entity, the number of shares
and the percentage of any class of voting stock of that affiliate owned, directly or indirectly, by that entity, and in the case
of an affiliate which controls that entity, the number of shares and the percentage of any class of voting stock of that entity
owned, directly or indirectly, by the affiliate.
f. If application is for an oil or gas pipeline, describe any related right-of-way or temporary use permit applications,
and identify previous applications.
g. If application is for an oil and gas pipeline, identify all Federal lands by agency impacted by proposal.
II - PUBLIC CORPORATIONS
a. Copy of law forming corporation
b. Proof of organization
c. Copy of Bylaws
d. Copy of resolution authorizing filing
e. If application is for an oil or gas pipeline, provide information required by item "I-f' and "I-g" above.
III - PARTNERSHIP OR OTHER UNINCORPORATED ENTITY
a. Articles of association, if any
b. If one partner is authorized to sign, resolution authorizing action is
c. Name and address of each participant, partner, association, or other
d. If application is for an oil or gas pipeline, provide information required by item "I-f" and "I-g" above.
* If the required information is already filed with the agency processing this application and is current, check block entitled "Filed." Provide the file iden-
tification information (e.g., number, date, code, name). If not on file or current, attach the requested information.
NOTICE
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0596-0082.
This information is needed by the Forest Service to evaluate the requests to use National Forest System lands and manage those lands to protect natural resources, administer the use, and ensure public health
and safety. This information is required to obtain or retain a benefit The authority for that requirement is provided by the Organic Act of 1897 and the Federal Land Policy and Management Act of 1976, which
authorize the secretary of Agriculture to promulgate rules and regulations for authorizing and managing National Forest System lands. These statutes, along with the Term Permit Act, National Forest Ski Area
Permit Act, Granger-Thye Act, Mineral Leasing Act, Alaska Term Permit Act , Act of September 3, 1954, Wildemess AcL National Forest Roads and Trails Act, Act of November 16, 1973, Archeological Re-
sources Protection Act, and Alaska National Interest Lands Conservation Act, authorize the Secretary of Agriculture to issue authorizations or the use and occupancy of National Forest System lands. The Sec-
retary of Agriculture's regulations at 36 CFR Part 251, Subpart B, establish procedures for issuing those authorizations.
The Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552) govern the confidentiality to be provided for information received by the Forest Service.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Department of Agriculture, Clearance Officer, Stop 7602,
1400 Independence Avenue S.W. Washington DC 20250-7602; and to the Office of Management and Budget, Office of Regulatory Affairs , Desk Officer for Forest Service, Washington, D.C. 20503.