10-904 LWCF Proposal Description and Environmental Screening Fo

NPS Form 10-904 (Rev. 09/2016) OMB Control No. 1024-0031

National Park Service Expiration Date XX/XX/2019

PROPOSAL DESCRIPTION AND ENVIRONMENTAL SCREENING FORM

Land and Water Conservation Fund

The purpose of this Proposal Description and Environmental Screening Form (PD/ESF) is to provide descriptive and environmental information about a variety of Land and Water Conservation Fund (LWCF) state assistance proposals submitted for National Park Service (NPS) review and decision. The completed PD/ESF becomes part of the “federal administrative record” in accordance with the National Environmental Policy Act (NEPA) and its implementing regulations. The PD portion of the form captures administrative and descriptive details enabling the NPS to understand the proposal. The ESF portion is designed for States and/or project sponsors to use while the LWCF proposal is under development. Upon completion, the ESF will indicate the resources that could be impacted by the proposal enabling States and/or project sponsors to more accurately follow an appropriate pathway for NEPA analysis: 1) a recommendation for a Categorical Exclusion (CE), 2) production of an Environmental Assessment (EA), or 3) production of an Environmental Impact Statement (EIS). The ESF should also be used to document any previously conducted yet still viable environmental analysis if used for this federal proposal. The completed PD/ESF must be submitted as part of the State’s LWCF proposal to NPS.

Except for the proposals listed below, the PD/ESF must be completed, including the appropriate NEPA document, signed by the State, and submitted with each new federal application for LWCF assistance and amendments for: scope changes that alter or add facilities and/or acres; conversions; public facility exceptions; sheltering outdoor facilities; and changing the original intended use of an area from that which was approved in an earlier LWCF agreement. Consult the LWCF Program Manual (www.nps.gov/lwcf) for detailed guidance for your type of proposal and on how to comply with NEPA.

For the following types of proposals only this Cover Page is required because these types of proposals are administrative in nature and are categorically excluded from further NEPA environmental analysis. NPS will complete the NEPA CE Form. Simply check the applicable box below, and complete and submit only this Cover Page to NPS along with the other items required for your type of proposal as instructed in the LWCF Program Manual.

SCORP planning proposal

Time extension with no change in project scope or with a reduction in project scope

To delete work and no other work is added back into the project scope

To change project cost with no change in project scope or with a reduction in project scope

To make an administrative change that does not change project scope

Name of LWCF Proposal:				Date Submitted to NPS:
LWCF Project Number:		Prior LWCF Project Number(s) and Park Name(s) Associated with the Assisted Site(s):
Local or State Project Sponsoring Agency (recipient, or sub-recipient in case of pass-through grants)
Name of Local or State Sponsor Contact:			Title
Address			City		State	Zip Code
Phone	Fax		Email Address

Using a separate sheet for narrative descriptions and explanations, address each item and question in the order it is presented, and identify each response with its item number such as Step 1-A1, A2; Step 3-B1; Step 6-A1, A29; etc.

Step 1. Type of LWCF Proposal

New Project Application

Acquisition

Development

Combination (Acquisition and Development

Go to Step A

Go to Step 2B

Go to Step 2C

New Project Application

Increase in scope or change in scope from original agreement. Complete Steps 3A, and 5 through 7.

6(f) conversion proposal. Complete Steps 3B, and 5 through 7.

Request for public facility in a Section 6(f) area. Complete Steps 3C, and 5 through 7.

Request for temporary non-conforming use in a Section 6(f) area. Complete Steps 4A, and 5 through 7.

Request for significant change in use/intent of original LWCF application. Complete Steps 4B, and 5 through 7.

Request to shelter existing/new facility within a Section 6(f) area regardless of funding source. Complete Steps 4C, and 5 through 7.

Step 2. New Project Application (See LWCF Manual for guidance)

A.

For an Acquisition Project

1.

Provide a brief narrative about the proposal that provides the reasons for the acquisition, the number of acres to be acquired with LWCF assistance, and a description of the property. Describe and quantify the types of existing resources and features on the site (for example, 50 acres wetland, 2,000 feet beachfront, 200 acres forest, scenic views, 100 acres riparian, vacant lot, special habitat, any unique or special features, recreation amenities, historic/cultural resources, hazardous materials/ contamination history, restrictions, institutional controls, easements, rights-of-way, above ground/underground utilities, including wires, towers, etc.).

2.

How and when will the site be made open and accessible for public outdoor recreation use (signage, entries, parking, site improvements, allowable activities, etc.)?

3.

Describe development plans for the proposal for the site(s) for public outdoor recreation use within the next three (3) years.

4.

SLO must complete the State Appraisal/Waiver Valuation Review form in Step 7 certifying that the appraisal(s) has been reviewed and meets the “Uniform Appraisal Standards for Federal Land Acquisitions” or a waiver valuation was approved per 49 CFR 24.102(c)(2)(ii). State should retain copies of the appraisals and make them available if needed.

5.

Address each item in “D” below.

B.

For a Development Project

1.

Describe the physical improvements and/or facilities that will be developed with federal LWCF assistance, including a site sketch depicting improvements, where and how the public will access the site, parking, etc. Indicate entrances on 6(f) map. Indicate to what extent the project involves new development, rehabilitation, and/or replacement of existing facilities.

2.

When will the project be completed and open for public outdoor recreation use?

3.

Address each item in “D” below.

C.

For a Combination Project

1.

For the acquisition part of the proposal:

a.

Provide a brief narrative about the proposal that provides the reasons for the acquisition, number of acres to be acquired with LWCF assistance, and describes the property. Describe and quantify the types of existing resources and features on the site (for example, 50 acres wetland, 2,000 feet beachfront, 200 acres forest, scenic views, 100 acres riparian, vacant lot, special habitat, any unique or special features, recreation amenities, historic/cultural resources, hazardous materials/ contamination history, restrictions, institutional controls, easements, rights-of-way, above ground/underground utilities, including wires, towers, etc.)

b.

How and when will the site be made open and accessible for public outdoor recreation use (signage, entries, parking, site improvements, allowable activities, etc.)?

c.

Describe development plans for the proposed for the site(s) for public outdoor recreation use within the next three (3) years.

d.

SLO must complete the State Appraisal/Waiver Valuation Review form in Step 7 certifying that the appraisal(s) has been reviewed and meets the “Uniform Appraisal Standards for Federal Land Acquisitions” or a waiver valuation was approved per 49 CFR 24.102(c)(2)(ii). State should retain copies of the appraisals and make them available if needed.

2.

For the development part of the proposal:

a.

Describe the physical improvements and/or facilities that will be developed with federal LWCF assistance, including a site sketch depicting improvements, where and how the public will access the site, parking, etc. Indicate entrances on 6(f) map. Indicate to what extent the project involves new development, rehabilitation, and/or replacement of existing facilities.

b.

When will the project be completed and open for public outdoor recreation use?

3.

Address each item in “D” below.

D.

For a Combination Project

1.

Will this proposal create a new public park/recreation area where none previously existed and is not an addition to an existing public park/recreation area? Yes (go to #3) No (go to #2)

2.

a.

What is the name of the pre-existing public area that this new site will be added to?

b.

Is the pre-existing public park/recreation area already protected under Section 6(f)? Yes No If no, will it now be included in the 6(f) boundary? Yes No

3.

What will be the name of this new public park/recreation area?

4.

a.

Who will hold title to the property assisted by LWCF? Who will manage and operate the site(s)?

b.

What is the sponsor’s type of ownership and control of the property?

Fee simple ownership

Less than fee simple. Explain:

Lease. Describe lease terms including renewable clauses, # of years remaining on lease, etc. Who will lease area? Submit copy of lease with this PD/ESF. (See LWCF Manual for program restrictions for leases and further guidance)

5.

Describe the nature of any rights-of-way, easements, reversionary interests, etc. to the Section 6(f) park area? Indicate the location on 6(f) map. Do parties understand that a Section 6(f) conversion may occur if private or non-recreation activities occur on any pre-existing right-of-way, easement, leased area?

6.

Are overhead utility lines present, and if so, explain how they will be treated per LWCF Manual.

7.

As a result of this project, describe new types of outdoor recreation opportunities and capacities, and short and long term public benefits.

8.

Explain any existing non-recreation and non-public uses that will continue on the site(s) and/or proposed for the future within the 6(f) boundary.

9.

Describe the planning process that led to the development of this proposal. Your narrative should address:

a.

How was the interested and affected public notified and provided opportunity to be involved in planning for and developing your LWCF proposal? Who was involved and how were they able to review the completed proposal, including any state, local, federal agency professionals, subject matter experts, members of the public and Indian Tribes. Describe any public meetings held and/or formal public comment periods, including dates and length of time provided for the public to participate in the planning process and/or to provide comments on the completed proposal.

b.

What information was made available to the public for review and comment? Did the sponsor provide written responses addressing the comments? If so, include responses with this PD/ESF submission.

10.

How does this proposal implement statewide outdoor recreation goals as presented in the Statewide Comprehensive Outdoor Recreation Plan (SCORP) (include references), and explain why this proposal was selected using the State’s Open Project Selection Process (OPSP).

11.

List all source(s) and amounts of financial match to the LWCF federal share of the project. The value of the match can consist of cash, donation, and in-kind contributions. The federal LWCF share and financial matches must result in a viable outdoor recreation area and not rely on other funding not mentioned here. Other federal resources may be used as a match if specifically authorized by law.

Source

Type of Match

Amount

12.

Is this LWCF project scope part of a larger effort not reflected on the SF-424 (Application for Federal Assistance) and grant agreement? If so, briefly describe the larger effort, funding amount(s) and source(s). This will capture information about partnerships and how LWCF plays a role in leveraging funding for projects beyond the scope of this federal grant.

13.

List all required federal, state, and local permits/approvals needed for the proposal and explain their purpose and status.

Proceed to Steps 5 through 7

Step 3. Project Amendment (See LWCF Manual for guidance)

A.

Increase/Change in Project Scope

1.

For Acquisition Projects: To acquire additional property that was not described in the original project proposal and NEPA documentation, follow Step 2A-Acquisition Project and 2D.

2.

For Development Projects: To change the project scope for a development project that alters work from the original project scope by adding elements or enlarging facilities, follow Step 2B-Development Project and 2D.

3.

For Combination Projects: Follow Step 2C as appropriate.

B.

Section 6(f)(3) Conversion Proposal

Prior to developing your Section 6(f)(3) conversion proposal, you must consult the LWCF Manual and 36 CFR 59.3 for complete guidance on conversions. Local sponsors must consult early with the State LWCF manager when a conversion is under consideration or has been discovered. States must consult with their NPS-LWCF manager as early as possible in the conversion process for guidance and to sort out and discuss details of the conversion proposal to avoid mid-course corrections and unnecessary delays. A critical first step is for the State and NPS to agree on the size of the Section 6(f) park land impacted by any non-recreation, non-public use, especially prior to any appraisal activity. Any previous LWCF project agreements and actions must be identified and understood to determine the actual Section 6(f) boundary. The Section 6(f)(3) conversion proposal including the required NEPA environmental review documents (CE recommendation or an EA document) must focus on the loss of public outdoor recreation park land and recreational usefulness, and its replacement per 36 CFR 59, and not the activities precipitating the conversion or benefits thereof, such as the impacts of constructing a new school to relieve overcrowding or constructing a hotel/restaurant facility to stimulate the local economy. Rather, the environmental review must: 1) focus on “resource impacts” as indicated on the ESF (Step 6), including the loss of public park land and recreation opportunities (ESF A-15), and 2) the impacts of creating new replacement park land and replacement recreation opportunities. A separate ESF must be generated for the converted park area and each replacement site. Section 6(f)(3) conversions always have more than minor impacts to outdoor recreation (ESF A-15) as a result of loss of parkland requiring an EA, except for “small” conversions as defined in the LWCF Manual Chapter 8. For NPS review and decision, the following elements are required to be included in the State’s completed conversion proposal to be submitted to NPS:

1.

A letter of transmittal from the SLO recommending the proposal.

2.

A detailed explanation of the sponsor’s need to convert the Section 6(f) parkland including all efforts to consider other practical alternatives to this conversion, how they were evaluated, and the reasons they were not pursued.

3.

An explanation of how the conversion is in accord with the State Comprehensive Outdoor Recreation Plan (SCORP).

4.

Completed “State Appraisal/Waiver Valuation Review form in Step 7 for each of the converted and replacement parcels certifying that the appraisals meet the “Uniform Appraisal Standards for Federal Land Acquisitions.” States must retain copies of the appraisals/waiver valuations and make them available for review upon request.

5.

For the park land proposed for conversion, a detailed description including the following:

a.

Specific geographic location on a map, 9-digit zip code, and name of park or recreation area proposed for conversion.

b.

Description of the area proposed for the conversion including the acreage to be converted and any acreage remaining. For determining the size of the conversion, consider not only the physical footprint of the activity precipitating the conversion, but how the precipitating activity will impact the entire 6(f) park area. In many cases the size of the converted area is larger than the physical footprint. Include a description of the recreation resources, facilities, and recreation opportunities that will be impacted, displaced or lost by the proposed conversion. For proposals to partially convert a Section 6(f) park area, the remaining 6(f) park land must remain recreationally viable and not be impacted by the activities that are precipitating the conversion. If it is anticipated that the precipitating activities impact the remaining Section 6(f) area, the proposed area for the conversion should be expanded to encompass all impacted park land.

c.

Description of the community and population served by the park, including users of the park and uses.

d.

For partial conversions, a revised 6(f) map clearly indicating both the portion that is being converted and the portion remaining intact under Section 6(f).

6.

For each proposed replacement site:

a.

Specific geographic location on a map, 9-digit zip code, and geographical relationship of converted and replacement sites. If site will be added to an existing public park/outdoor recreation area, indicate on map.

b.

Description of the site’s physical characteristics and resource attributes with number and types of resources and features on the site, for example, 15 acres wetland, 2,000 feet beachfront, 50 acres forest, scenic views, 75 acres riparian, vacant lot, special habitat, any unique or special features, structures, recreation amenities, historic/cultural resources, hazardous materials/contamination history, restrictions, institutional controls, easements, rights-of-way, overhead/underground utilities including overhead wires, towers, etc.

c.

Identification of the owner of the replacement site and its recent history of use/function up to the present.

	d.	Detailed explanation of how the proposed replacement site is of reasonably equivalent usefulness and location as the property being converted, including a description of the recreation needs that will be met by the new replacement parks, populations to be served, and new outdoor recreation resources, facilities, and opportunities to be provided.
	e.	Identification of owner and manager of the new replacement park?
	f.	Name of the new replacement park. If the replacement park is added to an existing public park area, will the existing area be included within the 6(f) boundary? What is the name of the existing public park area?
	g.	Timeframe for completing the new outdoor recreation area(s) to replace the recreation opportunity lost per the terms of conversion approval and the date replacement park(s) will be open to the public.
	h.	New Section 6(f) map for the new replacement park.
7.	NEPA environmental review, including NHPA Section 106 review, for both the converted and replacement sites in the same document to analyze how the converted park land and recreational usefulness will be replaced. Except for “small” conversions (see LWCF Manual Chapter 8), conversions usually require an EA.
Proceed to Steps 5 through 7
C.	Proposal for a Public Facility in a Section 6(f) Area
Prior to developing this proposal, you must consult the LWCF Manual for complete guidance. In summary, NPS must review and decide on requests to construct a public indoor and/or non-recreation facility within a Section 6(f) area. In certain cases NPS may approve the construction of public facilities within a Section 6(f) area where it can be shown that there will be a net gain in outdoor recreation benefits and enhancements for the entire park. In most cases, development of a non-recreation public facility within a Section 6(f) area constitutes a conversion. For NPS review, the State/sponsor must submit a proposal to NPS under a letter of transmittal from the SLO that:
1.	Describes the purpose and all proposed uses of the public facility such as types of programming, recreation activities, and special events including intended users of the new facility and any agency, organization, or other party to occupy the facility. Describe the interior and exterior of the facility, such as office space, meeting rooms, food/beverage area, residential/lodging area, classrooms, gyms, etc. Explain how the facility will be compatible with the outdoor recreation area. Explain how the facility and associated uses will significantly support and enhance existing and planned outdoor recreation resources and uses of the site, and how outdoor recreation use will remain the primary function of the site. (The public’s outdoor recreation use must continue to be greater than that expected for any indoor use, unless the site is a single facility, such as a swimming pool, which virtually occupies the entire site.)
2.	Indicates the exact location of the proposed public facility and associated activities on the site’s Section 6(f) map. Explain the design and location alternatives considered for the public facility and why they were not pursued.
3.	Explains who will own and/or operate and maintain the facility? Attach any 3rd party leases and operation and management agreements. When will the facility be open to the public? Will the facility ever be used for private functions and closed to the public? Explain any user or other fees that will be instituted, including the fee structure.
4.	Includes required documents as a result of a completed NEPA process (Steps 5 – 7).
Proceed to Steps 5 through 7
Step 4. Proposals for Temporary Non-Conforming Use, Significant Change in Use, and Sheltering Facilities (See LWCF Manual for guidance)
A.	Proposal for Temporary Non-Conforming Use
Prior to developing this proposal, you must consult the LWCF Manual for complete guidance. NPS must review and decided on requests for temporary uses that do not meet the requirements of allowable activities within a Section 6(f) area. A temporary non-conforming use is limited to a period of six months (180 days) or less. Continued use beyond six-months will not be considered temporary, and may result in a Section 6(f)(3) conversion of use requiring the replacement of converted parkland. For NPS review, describe the temporary non-conforming use (activities other than public outdoor recreation) in detail including the following information:
1.	A letter of transmittal from the SLO recommending the proposal.
2.	Describe in detail the proposed temporary non-conforming use and all associated activities, why it is needed, and alternative locations that were considered and why they were not pursued.
3.	Explain length of time needed for the temporary non-conforming use and why.
4.	Describe the size of the Section 6(f) area affected by the temporary non-conforming use activities and expected impacts to public outdoor recreation areas, facilities and opportunities. Explain efforts to keep the size of the area impacted to a minimum. Indicate the location of the non-conforming use on the site’s 6(f) map.
5.	Describe any anticipated temporary/permanent impacts to the Section 6(f) area and how the sponsor will mitigate them during and after the non-conforming use ceases.
6.	Consult the LWCF Manual for additional requirements and guidelines before developing the proposal.
Proceed to Steps 5 through 7

B.	Proposal for Significant Change in Use
Prior to developing the proposal, you must consult the LWCF Manual for complete guidance. NPS approval must be obtained prior to any change from one eligible use to another when the proposed use would significantly contravene the original plans or intent for the area outlined in the original LWCF application for federal assistance. Consult with NPS for early determination on the need for a formal review. NPS approval is only required for proposals that will significantly change the use of a LWCF-assisted site (e.g., from passive to active recreation). The proposal must include and address the following items:
1.	A letter of transmittal from the SLO recommending the proposal.
2.	Description of the proposed changes and how they significantly contravene the original plans or intent of LWCF agreements.
3.	Explanation of the need for change in use and how the change is consistent with local plans and the SCORP.
4.	Consult the LWCF Manual for additional requirements and guidelines before developing the proposal.
Proceed to Steps 5 through 7
C.	Proposal for Sheltering Facilities
Prior to developing this proposal, you must consult the LWCF Manual for complete guidance. NPS must review and decide on all proposals to shelter an existing outdoor recreation facility or construct a new sheltered recreation facility within a Section 6(f) area regardless of funding source. The proposal must demonstrate that there is an increased benefit to public recreation opportunity. Describe the sheltering proposal in detail, including the following:
1.	A letter of transmittal from the SLO recommending the proposal.
2.	Describe the proposed sheltered facility, how it would operate, how the sheltered facility will include recreation uses that could typically occur outdoors, and how the primary purpose of the sheltered facility is recreation.
3.	Explain how the sheltered facility would not substantially diminish the outdoor recreation values of the site including how the sheltered facility will be compatible and significantly supportive of the outdoor recreation resources present and/or planned.
4.	Explain how the sheltered facility will benefit the total park’s outdoor recreation use.
5.	Describe efforts provided to the public to review the proposal to shelter the facility and has local support.
6.	Document that the sheltered facility will be under the control and tenure of the public agency which sponsors and administers the original park area.
7.	Consult the LWCF Manual for additional requirements and guidelines before developing the proposal.
Proceed to Steps 5 through 7
Step 5. Summary of Previous Environmental Review (including E.O. 12372 - Intergovernmental Review)
To avoid duplication of effort and unnecessary delays, describe any prior environmental review undertaken at any time and still viable for this proposal or related efforts that could be useful for understanding potential environmental impacts. Consider previous local, state, federal (e.g. HUD, EPA, USFWS, FHWA, DOT) and any other environmental reviews. At a minimum, address the following:
1.	Date of environmental review(s), purpose for the environmental review(s) and for whom they were conducted.
2.	Description of the proposed action and alternatives.
3.	Who was involved in identifying resource impact issues and developing the proposal including the interested and affected public, government agencies, and Indian tribes?
4.	Environmental resources analyzed and determination of impacts for proposed actions and alternatives.
5.	Any mitigation measures to be part of the proposed action.
6.	Intergovernmental Review Process (Executive Order 12372): Does the State have an Intergovernmental Review Process? Yes No . If “Yes”, has the LWCF Program been selected for review under the State Intergovernmental Review Process? Yes No . If “Yes”, was this proposal reviewed by the appropriate State, metropolitan, regional and local agencies, and if so, attach any information and comments received about this proposal. If proposal was not reviewed, explain why not.
7.	Public comment periods (how long, when in the process, who was invited to comment) and agency response.
8.	Any formal decision and supporting reasons regarding degree of potential impacts to the human environment.
9.	Was this proposed LWCF federal action and/or any other federal actions analyzed/reviewed in any of the previous environmental reviews? If so, what was analyzed and what impacts were identified? Provide specific environmental review document references.
Use resource impact information generated during previous environmental reviews described above and from recently conducted site inspections to complete the Environmental Screening Form (ESF) portion of this PD/ESF under Step 6. Your ESF responses should indicate your proposal’s potential for impacting each resource as determined in the previous environmental review(s), and include a reference to where the analysis can be found in an earlier environmental review document. If the previous environmental review documents contain proposed actions to mitigate impacts, briefly summarize the mitigation for each resource as appropriate. The appropriate references for previous environmental review document(s) must be documented on the ESF, and the actual document(s) along with this PD/ESF must be included in the submission for NPS review.
Proceed to Steps 6 through 7
Step 6. Environmental Screening Form (ESF)
This portion of the PD/ESF is a working tool used to identify the level of environmental documentation which must accompany the proposal submission to the NPS. By completing the ESF, the project sponsor is providing support for its recommendation in Step 7 that the proposal either:
1.	meets criteria to be categorically excluded (CE) from further NEPA review and no additional environmental documentation is necessary; or
2.	requires further analysis through an environmental assessment (EA) or an environmental impact statement (EIS).
An ESF alone does not constitute adequate environmental documentation unless a CE is recommended. If an EA is required, the EA process and resulting documents must be included in the proposal submission to the NPS. If an EIS may be required, the State must request NPS guidance on how to proceed. The scope of the required environmental analysis will vary according to the type of LWCF proposal. For example, the scope for a new LWCF project will differ from the scope for a conversion. Consult the LWCF Manual for guidance on defining the scope or extent of environmental analysis needed for your LWCF proposal. As early as possible in your planning process, consider how your proposal/project may have direct, indirect and cumulative impacts on the human environment for your type of LWCF action so planners have an opportunity to design alternatives to lessen impacts on resources, if appropriate. When used as a planning tool in this way, the ESF responses may change as the proposal is revised until it is ready for submission for federal review. Initiating or completing environmental analysis after a decision has been made is contrary to both the spirit and letter of the law of the NEPA. The ESF should be completed with input from resource experts and in consultation with relevant local, state, tribal and federal governments, as applicable. The interested and affected public should be notified of the proposal and be invited to participate in scoping out the proposal (see LWCF Manual Chapter 4). At a minimum, a site inspection of the affected area must be conducted by individuals who are familiar with the type of affected resources, possess the ability to identify potential resource impacts, and to know when to seek additional data when needed. At the time of proposal submission to NPS for federal review, the completed ESF must justify the NEPA pathway that was followed: CE recommendation, production of an EA, or production of an EIS. The resource topics and issues identified on the ESF for this proposal must be presented and analyzed in an attached EA/EIS. Consult the LWCF Manual for further guidance on LWCF and NEPA. The ESF contains two parts that must be completed:
Part A. Environmental Resources Part B. Mandatory Criteria
Part A:		For each environmental resource topic, choose an impact estimate level (none, negligible, minor, exceeds minor) that describes the degree of potential negative impact for each listed resource that may occur directly, indirectly and cumulatively as a result of federal approval of your proposal. For each impacted resource provide a brief explanation of how the resource might be affected, how the impact level was determined, and why the chosen impact level is appropriate. If an environmental review has already been conducted on your proposal and is still viable, include the citation including any planned mitigation for each applicable resource, and choose an impact level as mitigated. If the resource does not apply to your proposal, mark NA in the first column. Add any relevant resources (see A.24 on the ESF) if not included in the list. Use a separate sheet to briefly clarify how each resource could be adversely impacted; any direct, indirect, and cumulative impacts that may occur; and any additional data that still needs to be determined. Also explain any planned mitigation already addressed in previous environmental reviews.
Part B:		This is a list of mandatory impact criteria that preclude the use of categorical exclusions. If you answer “yes” or “maybe” for any of the mandatory criteria, you must develop an EA or EIS regardless of your answers in Part A. Explain all “yes” and “maybe” answers on a separate sheet.

A. ENVIRONMENTAL RESOURCES Indicate potential for adverse impacts. Use a separate sheet to clarify responses per instructions for Part A on page 9.	Not Applicable - Resource does not exist	No/Negligible Impacts - Exists but no or negligible impacts	Minor Impacts	Impacts Exceed Minor EA/EIS required	More Data Needed to Determine Degree of Impact EA/EIS required
1. Geological resources: soils, bedrock, slopes, streambeds, landforms, etc.
2. Air quality
3. Sound (noise impacts)
4. Water quality/quantity
5. Stream flow characteristics
6. Marine/estuarine
7. Floodplains/wetlands
8. Land use/ownership patterns; property values; community livability
9. Circulation, transportation
10. Plant/animal/fish species of special concern and habitat; state/federal listed or proposed for listing
11. Unique ecosystems, such as biosphere reserves, World Heritage sites, old growth forests, etc.
12. Unique or important wildlife/ wildlife habitat
13. Unique or important fish/habitat
14. Introduce or promote invasive species (plant or animal)
15. Recreation resources, land, parks, open space, conservation areas, rec. trails, facilities, services, opportunities, public access, etc. Most conversions exceed minor impacts. See Step 3.B
16. Accessibility for populations with disabilities
17. Overall aesthetics, special characteristics/ features
18. Historical/cultural resources, including landscapes, ethnographic, archeological, structures, etc. Attach SHPO/THPO determination.
19. Socioeconomics, including employment, occupation, income changes, tax base, infrastructure
20. Minority and low-income populations
21. Energy resources (geothermal, fossil fuels, etc.)
22. Other agency or tribal land use plans or policies
23. Land/structures with history of contamination/hazardous materials even if remediated
24. Other important environmental resources to address.

B. Mandatory Criterial If your LWCF proposal is approved, would it…

Yes

No

To Be Determined

1. Have significant impacts on public health or safety?

2. Have significant impacts on such natural resources and unique geographic characteristics as historic or cultural resources; park, recreation, or refuge lands, wilderness areas; wild or scenic rivers; national natural landmarks; sole or principal drinking water aquifers; prime farmlands; wetlands (E.O. 11990); floodplains (E.O 11988); and other ecologically significant or critical areas.

3. Have highly controversial environmental effects or involve unresolved conflicts concerning alternative uses of available resources [NEPA section 102(2)(E)]?

4. Have highly uncertain and potentially significant environmental effects or involve unique or unknown environmental risks?

5. Establish a precedent for future action or represent a decision in principle about future actions with potentially significant environmental effects?

6. Have a direct relationship to other actions with individually insignificant, but cumulatively significant, environmental effects?

7. Have significant impacts on properties listed or eligible for listing on the National Register of Historic Places, as determined by either the bureau or office. (Attach SHPO/THPO Comments)

8. Have significant impacts on species listed or proposed to be listed on the List of Endangered or Threatened Species, or have significant impacts on designated Critical Habitat for these species.

9. Violate a federal law, or a state, local, or tribal law or requirement imposed for the protection of the environment?

10. Have a disproportionately high and adverse effect on low income or minority populations (Executive Order 12898)?

11. Limit access to and ceremonial use of Indian sacred sites on federal lands by Indian religious practitioners or significantly adversely affect the physical integrity of such sacred sites (Executive Order 13007)?

12. Contribute to the introduction, continued existence, or spread of noxious weeds or non-native invasive species known to occur in the area, or actions that may promote the introduction, growth, or expansion of the range of

Environmental Reviewers

The following individual(s) provided input in the completion of the environmental screening form. List all reviewers including name, title, agency, field of expertise. Keep all environmental review records and data on this proposal in state compliance file for any future program review and/or audit. The ESF may be completed as part of a LWCF pre-award site inspection if conducted in time to contribute to the environmental review process for the proposal.

1.

2.

3.

The following individuals conducted a site inspection to verify field conditions. List name of inspector(s), title, agency, and date(s) of inspection.

1.

2.

3.

State may require signature of LWCF sub-recipient applicant here:

Date:

Step 7. Recommended NEPA Pathway and State Appraisal/Waiver Valuation

First, consult the NPS list of Categorical Exclusions (CEs). If you find your action in the CE list and you have determined in Step 6A that impacts will be minor or less for each applicable environmental resource on the ESF and you answered “no” to all of the “Mandatory Criteria” questions in Step 6B, the proposal qualifies for a CE. Complete the following “State LWCF Environmental Recommendations” box indicating the CE recommendation.

If you find your action in the CE list and you have determined in Step 6A that impacts will be greater than minor or that more data is needed for any of the resources and you answered “no” to all of the “Mandatory Criteria” questions, your environmental review team may choose to do additional analysis to determine the context, duration, and intensity of the impacts of your project or may wish to revise the proposal to minimize impacts to meet the CE criteria. If impacts remain at the greater than minor level, the State/sponsor must prepare an EA for the proposal. Complete the following “State Environmental Recommendations” box indicating the need for an EA.

If you do not find your action in the CE list, regardless of your answers in Step 6, you must prepare an EA or EIS. Complete the following “State Environmental Recommendations” box indicating the need for an EA or EIS.

State NEPA Pathway Recommendation

I certify that a site inspection was conducted for each site involved in this proposal and to the best of my knowledge, the information provided in this LWCF Proposal Description and Environmental Screening Form (PD/ESF) is accurate based on available resource data. All resulting notes, reports and inspector signatures are stored in the state’s NEPA file for this proposal and are available upon request. On the basis of the environmental impact information for this LWCF proposal as documented in this LWCF PD/ESF with which I am familiar, I recommend the following LWCF NEPA pathway:

This proposal qualifies for a Categorical Exclusion (CE). CE Item #: Explanation:

This proposal requires an Environmental Assessment (EA) which is attached and has been produced by the State/sponsor in accordance with the LWCF Program Manual.

This proposal may require an Environmental Impact Statement (EIS). NPS guidance is requested per the LWCF Program Manual.

Reproduce this certificate as necessary. Complete for each LWCF appraisal or waiver valuation. State Appraisal/Waiver Valuation Review

Property Address:

$

Date of appraisal transmittal letter/waiver:

Real property value:

Effective date of value:

I certify that:

A State-certified Review Appraiser has reviewed the appraisal and has determined that it was prepared in conformity with the Uniform Appraisal Standards for Federal Land Acquisitions.

OR

The State has reviewed and approved a waiver valuation for this property per 49 CFR 24.102(c)(2)(ii).

SLO/ASLO Original Signature:

Date:

Typed Name

Title

Agency

NOTICES

Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by the Land and Water Conservation Fund Act of 1965 (54 U.S.C. 2003 et seq.). Your response is required to obtain or retain a benefit. We use this information to obtain descriptive and environmental information about the proposal. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number. OMB has assigned control number 1024-0031 to this collection.

Estimated Burden Statement

Completion times vary widely depending on the use of the form, from approximately 30 minutes to complete the cover page only to 500 hours for a difficult conversion of use. We estimate that the average completion time for this form is 8 hours for an application, 2 hours for an amendment, and 112 hours for a conversion of use, including the time necessary to review instructions gather data and review the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 12201 Sunrise Valley Drive, MS-242 Rm. 2C114, Reston, VA 20192. Please do not send your completed form to this address; but rather to the address at the top of the form.

RECORDS RETENTION - Permanent. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, Page 1 of 23

National Assistance Programs (Item 8.A.2) (N1-79-08-7))