3-2554 Request for Drain Tile Setback

FWS Form 3-2554 (Rev. 11/2023) OMB Control No. 1018-0196

U.S. Department of the Interior Expires ##/##/####

Request for Drain Tile Setback

U.S. FISH AND WILDLIFE SERVICE

National Wildlife Refuge System

Easement Number(s): ___________________________________________________

Requester Name: _______________________________________________________

Contact Information:

Address: _______________________________________________________________

Phone: _____________________________

Email: _________________________________________________________________

Technical Information:

Desired tile depths of installation, if known: __________________________________

_______________________________________________________________________

_______________________________________________________________________

Desired tile diameters of installation, if known: __________________________________

_______________________________________________________________________

_______________________________________________________________________

Please attach any Tile Installation Plan, if available

NOTICES

PRIVACY ACT STATEMENT

Authority: Fish and Wildlife Act of 1956, (16 U.S.C. 742a-742j-l); National Wildlife Refuge System Administration Act of 1966 (16 U.S.C. 668dd et seq.); National Wildlife Refuge System Improvement Act, PL 105-57, 111 Stat. 1252;

Purpose: The information provided will be used to provide upon request to landowners the setback distances required for the placement of drain tile on lands covered by wetland easements.

Routine Uses: This information may be shared in accordance with the Privacy Act of 1974 and the routine uses listed in the System of Records Notices, FWS-5, National Wildlife Refuge Special Use Permits - 64 FR 29055 (May 28, 1999); modification published 73 FR 31877 (June 4, 2008) and the FWS-21 Permits System – 68 FR 52610 (September 4, 2003); modification published 73 FR 31877 (June 4, 2008).

Disclosure: Furnishing this information is voluntary; however failure to provide all requested information may prevent the Service from being able to provide the distances.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501 et seq.), the U.S. Fish and Wildlife Service collects information necessary to provide setback distances to landowners for the placement of drain tile on lands covered by wetland easements. Your response is voluntary, but is required to obtain or retain a benefit. 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 currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1018-0196.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information to average 10 minutes for reporting and 15 minutes for recordkeeping, including 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 the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to this address.

FREEDOM OF INFORMATION ACT STATEMENT

Information provided to the Service is generally subject to release to the public under the Freedom of Information Act (FOIA). Certain information, however, may be subject to withholding if the Service determines that the information is a trade secret and/or commercial or financial information that is privileged or confidential. To the extent you are submitting business information that falls into one of these categories, you must clearly mark this information as "Business Confidential" in order for the Service to assess the applicability of FOIA Exemption 4. Any information provided by you that is not marked as “Business Confidential” will be considered releasable to the public under the FOIA [43 CFR 2.26 – 2.33].

For FWS Staff:

Date Received: ______________________

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