FS-2700-6b Recreation Residence Self-Inspection Report

USDA Forest Service FS-2700-6b(05/09)

OMB No. 0596-0082

RECREATION RESIDENCE SELF-INSPECTION REPORT

RANGER DISTRICT

ATTN:

ADDRESS

ADDRESS

FAX

PART I - TERMS AND CONDITIONS

Permit Holder/Primary & Mailing Address/Telephone					Tract: Lot #:
Yes No	1. Have you built or modified your structures during the past year? (Clause III-A) If yes, explain.
Yes No	2. Do you plan to construct or modify structures on the lot during the next year? (Clause III-B) If yes, explain.
Yes No		3. Do your structures meet state and local regulations and have you had an annual inspection if required by these entities? (Clause IV-A) If no, explain.
Yes No		4. Have you or do you plan to cut down any trees, altered the vegetation, or caused disturbance to the soil on the lot? (Clause IV-D) If yes, explain.
Yes No			5. Have your kept your structures and access road in good repair, and maintained a neat appearance on the lot? (Clause IV-E) If no, explain.
Yes No				6. Have you removed dangerous trees, limbs, or other hazardous conditions that could pose a risk of injury? (Clause IV-G) If no, explain what hazards exist.
Yes No				7. Have you paid your rental fees for the current year? (Clause VI) If no, explain.
Yes No				8. Have you received written approval for renting or subleasing your structures? (Clause VII-E) If no, explain.
Yes No				9. Are you planning to sell your structures in the next year? (Clauses IV-H & VII-C, D) If yes, request a FS-2700-3a form and complete.
Yes No				10. Are you living at the recreation residence full-time, to the exclusion of a home elsewhere? (Clause I-C) If yes, explain.

Comments:

Attach additional sheets, if necessary

Please sign, date, and return this form to your local Ranger District by: ____________________________________

PART II - OPERATION AND MAINTENANCE PLAN STANDARDS

!**USE THIS SECTION TO LIST STANDARDS FROM APPROVED LOCAL O & M PLANS**!

Item Inspected Meets Standard Action Required/Due Date

	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No
	Yes No

I certify that I have inspected the structures and permitted area, and the above information is accurate and true. I understand that any modifications to the structures and lot require prior written approval by the authorized officer.

___________________________________________ _________________________________

Signature of Permit Holder Date

____________________________________

Print Name

18 U.S.C. Section 1001 makes it a crime for any person knowingly and willfully to make to any department or agency of the United State any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.

Burden and Non-Discrimination Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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. The time required to complete this information collection is estimated to average 2.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

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.