10-904a Lwcf Compliance And Stewardship (c&s)

NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

COMPLIANCE AND STEWARDSHIP (C&S)
Land and Water Conservation Fund

Grant Name & Project Number(s):

Park Name(s):

LWCF Sponsor(s):

The purpose of the C&S form is to provide information about Land and Water Conservation Fund (LWCF) compliance and stewardship
proposals submitted for National Park Service (NPS) review. This form should be completed for any proposal that will impact a park or
other recreation area that received LWCF assistance. Consultation with the NPS should occur before the form is completed. All
proposals will be reviewed by the NPS in accordance with the LWCF Manual and other applicable federal laws, regulations, and
guidance.
Generally, all compliance actions require the completion of all of Section 3.0 – Resource Information. Any exceptions are noted in the
instructions for Section 3.0.
☐ Conversion of Use (fill out 1.0 with relevant sub-section(s), 3.0, and 4.0)
☐ All Conversions (1.1)
☐ Small Conversions (1.1 and 1.2)
☐ Other Compliance Actions Requiring NPS Review and Approval (fill out 2.0 with relevant sub-section(s), 3.0,
and 4.0)
☐ Sponsor Change (2.1)
☐ Significant Change in Use (2.2)
☐ Temporary Non-Conforming Use (2.3)
☐ Sheltering (2.4)
☐ New Public Facility (2.5)
Brief Description of the Proposal:
Click here to enter text.

RECORDS RETENTION – PERMANENT ACTIVE. (NPS Records Schedule, National Assistance Programs (Item 8.A.2) (N1-79-08-7))

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 1.0 CONVERSION OF USE
1.1 Required Information for All Conversions
Part A and B should be completed for all conversions, including full, partial, and small conversions.
A. Attachments checklist
☐ Transmittal letter from the SLO/ASLO that indicates the state’s support for the proposal
☐ LWCF project amendment form
☐ Documentation of NPS concurrence with the existing LWCF boundary area and the proposed conversion footprint
☐ Documentation of NPS concurrence that the proposed replacement property meets LWCF requirements
☐ Valuation documentation for conversion and replacement sites – either (a) appraisals and appraisal reviews OR (b) waiver valuations
(as applicable)
☐ NEPA documentation (as applicable)
☐ NHPA documentation (as applicable)
☐ Evidence of other federal law compliance as needed (i.e. ESA, CWA, etc.)
☐ Intergovernmental review comments (as applicable)
☐ DNF
☐ Maps:
☐ Signed and dated proposed LWCF boundary map(s) for the replacement site(s) and, for partial conversions, the original
remaining park site
☐ Site development plan for the proposed replacement property
☐ Site plan for the remaining parkland (for partial conversions)
☐ Location map depicting the locations of the conversion and the replacement properties and their relative location to one
another
B.

Basic conversion information

Reproduce tables as needed for multiple sites.
CONVERSION SUMMARY & APPRAISAL/WAIVER VALUATION CERTIFICATION
Conversion site

Name(s)
Converted acreage
Remaining acreages at site, if any
Fair market value
Appraisal effective date
☐ 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 prepared a waiver valuation for this property in conformity with
49 C.F.R. 24.102(c)(2)(ii)

Replacement site

Name(s)
Replacement acreage
Fair market value
Appraisal effective date
☐ 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 prepared a waiver valuation for this property in conformity with
49 C.F.R. 24.102(c)(2)(ii)

SLO/ASLO Signature

Date

Name, Title, and Agency

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

1.

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

2.

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

1.2 Additional Details for Small Conversions
The following section should be completed for small conversions only if you have been directed to do so after consultation with the
NPS.
1.

For the park land proposed for conversion, a detailed description including the following:
a. 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 LWCF 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 due to the proposed conversion. For
proposals to partially convert a LWCF park area, the remaining LWCF 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 will impact the remaining LWCF area, the proposed area for the conversion should be expanded to
encompass all impacted park land.
b.

2.

Description of the community and population(s) served by the park, including users of the park and recreation uses.

For each proposed replacement site:
a. 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.
b.

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

c.

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 and/or developed at the new
replacement parks, population(s) to be served, and new outdoor recreation resources, facilities, and opportunities to
be provided.

d.

Identification of owner and manager of the new replacement park.

e.

Name of the new replacement park. If the replacement park land will be added to an existing public park area, the
existing area is expected to be included within the LWCF boundary. What is the name of the existing public park
area? Is the existing park already LWCF-protected?

f.

Timeframe for completing development of the new outdoor recreation area(s) to replace the recreation opportunity
lost per the terms of conversion approval and the date the replacement park(s) will be open to the public.

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 2.0 OTHER COMPLIANCE ACTIONS FOR NPS REVIEW AND APPROVAL
2.1 Sponsor Change
A change in sponsor is an administrative change so the completion of Section 3.0 – Resource Information is not necessary.
A. Attachments checklist
☐ LWCF project amendment form
☐ LWCF boundary map with signature/date by the new sponsor and the state
B.

Description
1. Why is the change in sponsor necessary?
2.

What is the process and timeline for amending the state/local LWCF agreement?

3.

What is the legal name of the proposed new sponsor? Are they an eligible sponsor for the LWCF program?

2.2 Significant Change in Use
A. Attachments checklist
☐ Transmittal letter or email from the SLO/ASLO that indicates the state’s support for the proposal
☐ Map – site plan showing the location of the proposed use in relation to the LWCF boundary
B.

Description
1. Description of the proposed changes and how they significantly contravene the original plans or intent for use of the site as
documented in the LWCF grant agreement(s).
2.

Explanation of the need for change in use and how the change is consistent with local plans and the goals and objectives of the
current SCORP.

2.3 Temporary Non-Conforming Use
A. Attachments checklist
☐ Transmittal letter from the SLO/ASLO that indicates the state’s support for the proposal
☐ Maps:
☐ Drawings and/or renderings of the proposed use
☐ Site plan showing the location of the proposed use in relation to the LWCF boundary
B.

Description
1. 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.
2.
3.

Explain length of time needed for the temporary non-conforming use and why.
Describe the size of the LWCF area that will be affected by the temporary non-conforming use activities and expected
impacts to public outdoor recreation areas, facilities and opportunities. Explain plans or efforts to keep the size of the area
impacted to a minimum.

4.

Describe any anticipated temporary/permanent impacts to the LWCF area and how the sponsor will mitigate them during and
after the non-conforming use ceases.

2.4 Sheltering
An enclosed or sheltered recreation facility is defined as a facility that was originally assisted by LWCF or would be eligible for LWCF
assistance if it was to be outdoors. LWCF assistance may be provided to shelter swimming pools and ice skating rinks only, when they
are located in areas that meet specific cold climatic criteria. Project sponsors may seek approval to shelter or enclose other types of
recreation facilities at their own expense, regardless of prevailing climatic conditions.
A. Attachments checklist
☐ Transmittal letter from the SLO/ASLO that indicates the state’s support for the proposal
☐ Drawings and/or renderings of the proposed facility
☐ Site plan showing the location of the facility to be enclosed in relation to the LWCF boundary
☐ Provide a copy of the cold climatic data used to make the eligibility determination (if applicable; see
manual).
B.

Description
1. (If applicable) Explain how it was determined that the site meets the cold climate criteria described in the LWCF manual.

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

2.

Describe the proposed sheltered facility, how it would operate, the recreation uses that could typically occur outdoors, and how
the primary purpose of the sheltered facility will be 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 with 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 that sponsors and administers the
underlying park area.

2.5 New Public Facility
A. Attachments checklist
☐ Transmittal letter from the SLO/ASLO that indicates the state’s support for the proposal, why it would result in a net benefit to outdoor
recreation at the site, and the life expectancy of the facility.
☐ Maps:
☐Drawings and/or renderings of the proposed facility
☐ Site plan showing the location of the proposed use (and any surrounding impacted area) in relation to the LWCF boundary
B.

Description
1. Describe 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.
2.

Explain how the facility will be compatible with and not diminish 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.)

3.

Explain the design and location alternatives considered for the public facility and why they were not pursued.

4.

Explain 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.

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

SECTION 3.0 RESOURCE INFORMATION
Consultation with NPS regarding the NEPA pathway for a proposal should occur prior to completing this section. If has already been
determined that the proposal will require an EA or EIS, you may go directly to the questions following Tables 1 and 2. The
Environmental Resources Survey should be reproduced and completed for the conversion site(s) and the replacement site(s).
A. Environmental resources survey
The tables below serve as a record of the environmental resources present at the site, whether the proposed action is likely to have a
significantly negative impact those resources, and whether further information is needed to determine the potential impact. Review the
listed resources and identify any resources that may be significantly impacted by the action. The Environmental Resources Survey
should be completed with professional input from resource experts and in consultation with relevant local, state, tribal, and federal
governments, as appropriate.
Table 1 – For each resource indicate if positive impacts or negative impacts are anticipated to result from the action or if further
information is needed to determine the potential impact.
+ indicates positive impacts are anticipated to result from the action
- indicates negative impacts are anticipated to result from the action
? indicates further information is needed to determine the potential impact
Site Name:
How will the project affect the following resources?
1
2
3
4

Air quality
Circulation and transportation
Climate

5
6
7

Endangered species: (listed or proposed threatened or endangered) including associated habitat
Environmental justice: minority and low-income populations

Contamination or hazardous materials even if remediated

Geological resources: soils, bedrock, slopes, streambeds, landforms, etc.

+

☐
☐
☐
☐
☐
☐
☐

-

☐
☐
☐
☐
☐
☐
☐

?

☐
☐
☐
☐
☐
☐
☐

Historic or cultural resources
☐
☐
☐
Invasive species
☐
☐
☐
Land use plans or policies from other agencies including tribes
☐
☐
☐
☐
☐
☐
Lightscapes especially night sky
12
Migratory birds
☐
☐
☐
13
Recreation resources
☐
☐
☐
14
Socioeconomics: changes to tax base or competition with private sector
☐
☐
☐
15
Sound (noise impacts)
☐
☐
☐
16
Unique ecosystems, such as biosphere reserves, World Heritage sites, old growth forests, etc.
☐
☐
☐
17
Water quality and/or quantity
☐
☐
☐
18
Water: coastal barrier resources or coastal zones
☐
☐
☐
19
Water: marine and/or estuarine
☐
☐
☐
20
Water: stream flow characteristics
☐
☐
☐
21
Water: wetlands and floodplains
☐
☐
☐
22
Other important resources
☐
☐
☐
Explain:
Table 2 – This is a list of mandatory impact criteria that preclude the use of a categorical exclusion. If you answer “yes” or “?” for any of
the mandatory criteria, you must develop an EA or EIS regardless of your answers in table 1.
8
9
10
11

Site Name:
Will your proposal:
1

Have significant negative impacts on public health or safety?

2

Have significant negative impacts on unique natural resource or geographic characteristics such 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; floodplains; national monuments; migratory birds; and other ecologically significant or
critical areas?

3

Have highly controversial environmental effects or involve unresolved conflicts concerning alternative
uses of available resources?

Y

N

?

☐

☐

☐

☐

☐

☐

☐

☐

☐

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

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?
Have significant adverse effects on properties listed or eligible for listing in the National Register of
Historic Places as determined by NPS?

☐

☐

☐

☐

☐

☐

7
8

Have significant negative impacts to 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 (EO
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?

☐

☐

☐

12

Contribute to the introduction, continued existence, or spread of noxious weeds or nonnative invasive
species known to occur in the area or actions that may promote the introduction, growth, or
expansion of the range of such species?

☐

☐

☐

1.

Have there been any previous NEPA/SEPA documents prepared that are relevant to this proposal or this specific site?
a. ☐ No
b. ☐ Yes – Attach and summarize findings and include page number references below

2.

Explain any negative or unknown impacts identified in Table 1 of the Environmental Resources Survey or any boxes marked
“yes” in Table 2 (mandatory criteria).

3.
4.

How was the information in the tables derived and what sources of data were used to justify the impact selection?
Who contributed to filling out the Environmental Resources Survey (include name, title, agency) and what qualifications do
they have that provide the necessary resource expertise to determine impact significance?

5.

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

NEPA Pathway Recommendation
Attach documentation of NPS concurrence with the recommended NEPA Pathway
☐ This proposal qualifies for a Categorical Exclusion (CE). List: __________
☐ This proposal requires an Environmental Assessment (EA), which is attached and has been produced in accordance
with the LWCF Manual
☐ This proposal may require an Environmental Impact Statement (EIS)
B. Cultural and historic resources review
Have there been any previous cultural and/or historic resource surveys completed that included this site within the area of potential
effect that was assessed?
☐ No – Describe any construction planned as a result of this project that will extend beyond the pre-existing disturbance area (including
surface area and depth).
☐ Yes – Attach survey and summarize findings and include page number references below.

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NPS Form 10-904A (Rev. 12/2019)
National Park Service

OMB Control No. 1024-0031
Expiration Date xx/xx/xxxx

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. 200301 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. We estimate that the average completion time for this form is 16 hours
for most stewardship requests, and 92.5 hours for a conversion of use (although a difficult conversion can take up to 500 hours),
including the time necessary to read, gather data, review instructions, and complete the form. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Phadrea Ponds, Acting
NPS Information Collection Clearance Officer, 1201 Oakridge Drive, Fort Collins, CO 80525. Please do not send your completed form
to this address.

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