Form FS-2700-4d Special Use Permit for a Temporary Road Covered by a Cos

Authorization ID: #AUTH_ID# FS-2700-4d (XX/202X)

Contact ID: #HOLDER_ID# OMB No. 0596-0082

Expiration Date: #EXPIRATION_DATE#

Use Code: #USE_CODE#

U.S. DEPARTMENT OF AGRICULTURE

Forest Service

SPECIAL USE PERMIT FOR A TEMPORARY ROAD COVERED BY A COST SHARE AGREEMENT AUTHORITY:

#AUTHORITY_NAME#

#HOLDER_NAME#, #HOLDER_ADD_LINE_1#, #HOLDER_ADD_LINE_2#, #HOLDER_ADD_LINE_3#,

#HOLDER_CITY#, #HOLDER_STATE# #HOLDER_ZIP# (hereafter called the holder) is hereby authorized to use National Forest lands for the construction, reconstruction, maintenance, and use of a road within the

______________ National Forest for the protection, administration, management, and utilization of lands and the

resources thereof now or hereafter owned or controlled by the holder. The lands covered by this permit are located in the County of _______________State of _______________and are described as follows:

#PURPOSE#

#TOWNSHIP_SECT_RANGE#

#FIRST_DIVISION# #FIRST_DIV_NAME_NUMBER#, #SECOND_DIVISION#

#SECOND_DIV_NAME_NUMBER#, #THIRD_DIVISION# #THIRD_DIV_NAME_NUMBER#

This permit covers a right-of-way #ROW_LENGTH_MILES# miles in length, #ROW_WIDTH_FEET# feet in width, containing approximately #ROW_ACRES# acres, and is located upon the ground according to the survey line, figures, measurements, widths, and other references shown on the plat attached hereto and made a part hereof.

This permit is made subject to the following terms, provisions, and conditions:

1. This permit is subject to all valid rights existing on this date.

2. The holder, in exercising the privileges granted by this permit, shall comply with all applicable State and Federal laws, Executive Orders, and Federal rules and regulations.

3. The holder shall cut only such timber as necessary in clearing for road construction, reconstruction, and maintenance. Timber so cut shall, unless otherwise agreed to, be cut into logs of lengths specified by the Forest Service and decked along the road for disposal by the Forest Service.

4. The holder shall do everything reasonably within its power to prevent forest fires and shall not dispose of material by burning in open fires during the closed season established by law or regulation without a written permit from the Forest Service.

5. The holder shall repair fully all damage to National Forest roads and trails caused by the holder in exercise of the privileges granted by this permit.

6. No member of or delegate to Congress or resident commissioner shall be admitted to any share or part of this agreement or to any benefit that may arise herefrom unless it is made with a corporation for its general benefit.

7. In consideration for this use, the holder has granted reciprocal rights-of-way to the United States.

8. Construction of the road shall be in accordance with the specifications set forth in exhibit ______________, attached hereto.

9. The holder shall provide maintenance so that the road will be in a condition equal to that normally prevailing on roads of like standard, and unless otherwise agreed to, shall construct leadoff drainage and water barriers to prevent erosion on the road as directed by the Forest Service.

10. Use of roads constructed under authority of this permit shall be subject to control by the holder, except that the roads shall at all times be open to use by Forest Service employees on official business.

11. The holder shall maintain the right-of-way clearing by means of chemicals only after the Regional Forester has given specific written approval. Application for such approval must be in writing and must specify the time, method, chemicals and the exact portion of the right-of-way to be chemically treated.

12. In the event the road constructed on the right-of-way herein is included in a subsequent cooperative agreement for joint construction, the Government shall treat the holder's construction costs as incurred under the agreement. In this event, the Government shall replace this permit with an easement as provided by regulations of the Secretary of Agriculture (36 CFR 212.10c).

13. This permit may be terminated or suspended upon breach of any of the conditions herein or at the discretion of the Regional Forester or the Chief, Forest Service.

14. Unless sooner terminated in accordance with the provisions of the permit, or revoked by the Regional Forester, this permit shall expire and become void on #EXPIRATION_DATE#.

#INSERT TERM HERE#

In Witness Whereof, the parties hereto have caused this permit to be duly executed on this _______________ day ______________________.

.

Holder_____________________________ USDA - Forest Service

By:________________________________ BY:_______________________________

#HOLDER_NAME# Forest Supervisor

______________________National Forest

PAPERWORK REDUCTION ACT STATEMENT

According to the Paperwork Reduction Act of 1995, a Federal agency may not conduct or sponsor, and a person is not required to respond to, an information collection request unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection request is 0596-0082. Response to this information collection request is required to obtain or retain benefits, specifically, a special use authorization. The authority for this information collection request is #AUTHORITY_NAME#. The time required to complete this information collection request is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, collecting and maintaining the data needed, and completing and reviewing the information collection request. Send comments regarding this burden estimate or any other aspect of this information collection request, including suggestions for reducing the burden, to Forest Service Information Collections Officer, [email protected], with OMB control number 0596-0082 in the subject line.

PRIVACY ACT STATEMENT

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act statement serves to inform you of the following concerning the collection of the information on this form.

Purpose:  The Privacy Act of 1974 requires that the Director of Recreation, Heritage, and Volunteer Resources staff and the Director of Lands, Minerals, and Geology Management staff provide the following statements to individuals from whom they request information.

Authority:  Collection of this information solicited on this form is authorized by #AUTHORITY_NAME#.

Routine Uses:  The information collected will be used by Forest Service officials to ensure that your use of National Forest System lands is administered in accordance with applicable statutes, regulations, and directives. The information collected from you is retained in the Special Uses Data System (SUDS) and is retrieved by the Forest Service create reports for the Agency’s Special Uses Program, generate bills for collection of land use fees for your authorization, monitor compliance with your special use authorization, and other matters pertaining to administration of your special use authorization. SUDS is a component of the Forest Service’s Natural Resources Manager database (NRM). A complete list of the routine uses of NRM can be found in the system of records notice associated with this form, FS-24.

Disclosure:  The submission of this information is required to obtain or retain benefits, specifically, a special use authorization.

NONDISCRIMINATION STATEMENT

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).  Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible agency or USDA’s TARGET Center at (202) 720-2600 (voice and TYY) or contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all the information requested in the form.  To request a copy of the complaint form, call (866) 632-9992.  Submit the completed form or letter to USDA by (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. 

USDA is an equal opportunity provider, employer, and lender.

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