Form FS-2700-25 Temporary Special Use Permit

Authorization ID:  #AUTH_ID#                                                                   FS-2700-25 (XX/202X)

Contact Name: #HOLDER_ID# OMB NO. 0596-0082

Expiration Date: #EXPIRATION_DATE#

Use Code: #USE_CODE#

U.S. DEPARTMENT OF AGRICULTURE

FOREST SERVICE

TEMPORARY SPECIAL USE PERMIT

(FSH 2709.11, sec. 54.6)

AUTHORITY:

ACT OF MAY 26, 2000, PL 106-206 May 26, 2000

  

#HOLDER_NAME# of #HOLDER_ADD_LINE_1#, #HOLDER_ADD_LINE_2#, #HOLDER_ADD_LINE_3#, #HOLDER_CITY#, #HOLDER_STATE#  #HOLDER_ZIP#, hereinafter called the Holder, is hereby authorized to use, subject to the terms and conditions of this permit, National Forest System land identified within the unit area and described as , , as shown on the attached Exhibit(s) .  This authorization covers approximately #USE_ACRES# acres and/or #USE_MILES# miles.

 

The holder is authorized to conduct the following activities and/ or install the following temporary improvements on the permitted area:

#PURPOSE#

 

TERMS AND CONDITIONS

 

A.  Use under this permit shall begin on #Date# and end on #EXPIRATION DATE#. The permit shall not be extended.

 B.   The fee for this use is $ Amount. It shall be paid in advance and is not refundable.

 C.  The holder shall conduct the authorized activities according to the attached approved plans and specifications, Exhibit(s) .

 D.   The holder shall not install any improvements not specifically identified and approved above.

 E.  No soil, trees, or other vegetation may be destroyed or removed from National Forest System lands without specific prior written permission from the authorized officer.

 F.  The holder shall comply with all Federal, State, county, and municipal laws, ordinances, and regulations which are applicable to the area or operations covered by this permit.

 G.  The holder shall maintain the improvements and premises to standards of repair, orderliness, neatness, sanitation, and safety acceptable to the authorized officer.  The holder shall fully repair and bear the expense for all damage, other than ordinary wear and tear, to National Forest System lands, roads and trails caused by the holder's activities.

H.  The holder has the responsibility of inspecting the use area and adjoining areas for dangerous trees, hanging limbs, and other evidence of hazardous conditions which would pose a risk of injury to individuals.  After securing permission from the authorized officer, the holder shall remove such hazards.

 I.  The holder shall be liable for any damage suffered by the United States resulting from or related to use of this permit, including damages to National Forest resources and costs of fire suppression.

 J.  The holder shall hold harmless the United States from any liability from damage to life or property arising from the holder's occupancy or use of National Forest lands under this permit.

K.  The holder agrees to permit the free and unrestricted access to and upon the premises at all times for all lawful and proper purposes not inconsistent with the intent of the permit or with the reasonable exercise and enjoyment by the holder of the privileges thereof.

L.  This permit is subject to all valid existing rights and claims outstanding in third parties.

M.  This permit may be revoked upon breach of any of the conditions herein or at the discretion of the authorized officer.  Upon expiration or revocation of this permit, the holder shall immediately remove all improvements except those owned by the United States, and shall restore the site within day(s), unless otherwise agreed upon in writing.  If the holder fails to remove the improvements, they shall become the property of the United States, but that will not relieve the holder of liability for the cost of their removal and restoration of the site.

 N.  This permit is a license for the use of federally owned land.  It does not grant any interest in real property.  This permit is not transferable.  The holder shall not enter into any agreements with third parties for occupancy of the authorized premises and improvements.

O.  Appeal of any provisions of this permit or any requirements thereof shall be subject to the appeal regulations at 36 CFR 214, or revisions thereof.

P.  This permit is accepted subject to the conditions set forth herein, condition(s) and Exhibit(s) attached to and made a part of this permit.

 Q.  This permit, and any appendices incorporated into this permit by reference, constitute the complete understanding of the parties to this permit as to the rights, duties, and obligations of each party as of the date of issuance of this permit. If there are any inconsistencies between any of the preceding clauses and any subsequent clauses or any appendices to this permit, the preceding clauses shall govern.

I have read and understand the terms and conditions and agree to abide by them.

 

HOLDER:

BY:___________________________________________________

ADDRESS:_____________________________________________

PHONE:_______________________________________________

DATE:________________________________________________

US DEPARTMENT OF AGRICULTURE

FOREST SERVICE:

BY:___________________________________________________

NAME:________________________________________________

(AUTHORIZED OFFICER)

TITLE:________________________________________________

DATE:_________________________________________________

___________________________________________________________________________________

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 the ACT OF MAY 26, 2000, PL 106-206 May 26, 2000. 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 the ACT OF MAY 26, 2000, PL 106-206 May 26, 2000.

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.