Fillable Stelprdb5353853 SF 299 (USDA Forest Service)

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Stelprdb5353853 SF 299 (USDA Forest Service)

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STANDARD FORM 299 (5/2009)
Prescribed by DOI/USDA/DOT
P.L. 96487 and Federal
Register Notice 5-22-95
APPLICATION FOR TRANSPORTATION AND
UTILITY SYSTEMS AND FACILITIES
ON FEDERAL LANDS
Date filed
FOR AGENCY USE ONLY
Application Number
Applicant
Authorized Agent
3. TELEPHONE (area code)
FORM APPROVED
OMB NO. 1004-0189
Expires: April 30, 2012
NOTE: Before completing and filing the application, the applicant should completely review this package and schedule a
preapplication meeting with representatives of the agency responsible for processing the application. Each agency
may have specific and unique requirements to be met in preparing and processing the application. Many times, with
the help of the agency representative, the application can be completed at the preapplication meeting.
1. Name and address of applicant (include zip code) 2. Name, title, and address of authorized agent if different
from Item 1 (include zip code)
4. As applicant are you? (check one) 5. Specify what application is for: (check one)
a.
Individual
b.
Corporation*
c.
Partnership/Association*
d.
State Government/State Agency
e.
Local Government
f.
Federal Agency
* If checked, complete supplemental page
a. New authorization
b. Renewing existing authorization No.
c. Amend existing authorization No.
d. Assign existing authorization No.
e. Existing use for which no authorization has been received*
f. Other*
*If checked provide details under Item 7
6. If an individual, or partnership are you a citizen(s) of the United States?
Yes No
7. Project description (a) Type of system or facility, (e.g., canal, pipeline, road); (b) related structures and facilities; (c) physical specifications
(length, width, grading, etc.); (d) term of years needed; (e) time of year of use or operation; (f) Volume or amount of product to be transported; (g) duration and
timing of construction; and (h) temporary work areas needed for construction (Attach additional sheets, if additional space is needed,)
(describe in detail):
8. Attach a map covering area and show location of project proposal
Attached Applied for
9. State or local government approval:
Not required
Not required
Attached
10. Nonreturnable application fee.
Yes No
(If “yes,” indicate on map)
11. Does project cross international boundary or affect international waterways?
12. Give statement of your technical and financial capability to construct, operate, maintain, and terminate system for which authorization is being requested.
(Continued on page 2 )
This form is authorized for local reproduction.
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13a. Describe other reasonable alternative routes and modes considered.
b. Why were these alternatives not selected?
c. Give explanation as to why it is necessary to cross Federal Lands
14. List authorizations and pending applications filed for similar projects which may provide information to the authorizing agency. (Specify number, date, code, or name)
15. Provide statement of need for project, including the economic feasibility and items such as: (a) cost of proposal (construction, operation, and maintenance); (b)
estimated cost of next best alternative; and (c) expected public benefits.
16. Describe probable effects on the population in the area, including the social and economic aspects, and the rural lifestyles.
17. Describe likely environmental effects that the proposed project will have on: (a) air quality; (b) visual impact; (c) surface and ground water quality and quantity; (d)
the control or structural change on any stream or other body of water; (e) existing noise levels; and (f) the surface of the land, including vegetation, permafrost, soil,
and soil stability.
18. Describe the probable effects that the proposed project will have on (a) populations of fish, plantlife, wildlife, and marine life, including threatened and endangered
species; and (b) marine mammals, including hunting, capturing, collecting, or killing these animals.
19. State whether any hazardous material, as defined in this paragraph, will be used, produced, transported or stored on or within the right-of-way or any of the right-of-way
facilities, or used in the construction, operation, maintenance or termination of the right-of-way or any of its facilities. “Hazardous material” means any substance,
pollutant or contaminant that is listed as hazardous under the Comprehensive Environmental Response, Compensation, and Liability Act of 1980, as amended, 42 U.S.C.
9601 et seq., and its regulations. The definition of hazardous substances under CERCLA includes any “hazardous waste” as defined in the Resource Conservation and
Recovery Act of 1976 (RCRA), as amended, 42 U.S.C. 9601 et seq., and its regulations. The term hazardous materials also includes any nuclear or byproduct material
as defined by the Atomic Energy Act of 1954, as amended, 42 U.S.C. 2011 et seq. The term does not include petroleum, including crude oil or any fraction thereof that
is not otherwise specifically listed or designated as a hazardous substance under CERCLA Section 101(14), 42 U.S.C. 9601(14), nor does the term include natural gas.
20. Name all the Department(s)/Agency(ies) where this application is being filed.
I HEREBY CERTIFY, That I am of legal age and authorized to do business in the State and that I have personally examined the information contained in the application and
believe that the information submitted is correct to the best of my knowledge.
Date
Signature of Applicant
Title 18, U.S.C. Section 1001 and Title 43 U.S.C. Section 1212, make it a crime for any person knowingly and willfully to make to any department or agency of the United
States any false, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.
(Continued on page
3
)
(SF-299, page 2)
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APPLICATION FOR TRANSPORTATION AND UTILITY SYSTEMS
AND FACILITIES ON FEDERAL LANDS
GENERAL INFORMATION
ALASKA NATIONAL INTEREST LANDS
This application will be used when applying for a right-of-way, permit,
license, lease, or certificate for the use of Federal lands which lie within
conservation system units and National Recreation or Conservation
Areas as defined in the Alaska National Interest Lands Conservation Act.
Conservation system units include the National Park System, National
Wildlife Refuge System, National Wild and Scenic Rivers System,
National Trails System, National Wilderness Preservation System, and
National Forest Monuments.
Transportation and utility systems and facility uses for which the
application may be used are:
1. Canals, ditches, flumes, laterals, pipes, pipelines, tunnels, and other
systems for the transportation of water.
2. Pipelines and other systems for the transportation of liquids other than
water, including oil, natural gas, synthetic liquid and gaseous fuels, and
any refined product produced therefrom.
3. Pipelines, slurry and emulsion systems, and conveyor belts for
transportation of solid materials.
4. Systems for the transmission and distribution of electric energy.
5. Systems for transmission or reception of radio, television, telephone,
telegraph, and other electronic signals, and other means of
communications.
6. Improved rights-of-way for snow machines, air cushion vehicles, and
all-terrain vehicles.
7. Roads, highways, railroads, tunnels, tramways, airports, landing strips,
docks, and other systems of general transportation.
This application must be filed simultaneously with each Federal
department or agency requiring authorization to establish and operate
your proposal.
In Alaska, the following agencies will help the applicant file an application
and identify the other agencies the applicant should contact and possibly
file with:
U.S. Department of Agriculture
FOREST SERVICE (USFS)
Alaska Regional Office (Region 10)
Physical Address:
Federal Office Building
709 West 9th Street
Juneau, Alaska 99801
Mailing Address:
P.O. Box 21628
Juneau, Alaska 99802
Telephone: 907-586-8806
U.S. Department of the Interior
BUREAU OF INDIAN AFFAIRS (BIA)
Alaska Regional Office (Juneau)
Mailing/Physical Address:
P.O. Box 25520
709 West 9th Street
Juneau, Alaska 99802
Telephone: 800-645-8397
U.S. Department of the Interior
BUREAU OF LAND MANAGEMENT (BLM)
Alaska State Office
Mailing/Physical Address:
222 West 7th Avenue #13
Anchorage, Alaska 99513
Telephone: 907-271-5960
U.S. Department of the Interior
NATIONAL PARK SERVICE (NPS)
Alaska Regional Office (Anchorage)
Mailing/Physical Address:
240 West 5th Avenue, Room 114
Anchorage, Alaska 99501
Telephone: 907-644-3501
NOTE - The Department of Transportation has established the above central
filing point for agencies within that Department. Affected agencies are: Federal
Aviation Administration (FAA), Coast Guard (USCG), Federal Highway
Administration (FHWA), Federal Railroad Administration (FRA).
OTHER THAN ALASKA NATIONAL INTEREST LANDS
Use of this form is not limited to National Interest Conservation Lands of
Alaska.
Individual departments/agencies may authorize the use of this form by
applicants for transportation and utility systems and facilities on other Federal
lands outside those areas described above.
For proposals located outside of Alaska, applications will be filed at the local
agency office or at a location specified by the responsible Federal agency.
SPECIFIC INSTRUCTIONS
(Items not listed are self-explanatory )
Item
7 Attach preliminary site and facility construction plans. The responsible
agency will provide instructions whenever specific plans are required.
8 Generally, the map must show the section(s), township(s), and ranges within
which the project is to be located. Show the proposed location of the project
on the map as accurately as possible. Some agencies require detailed survey
maps. The responsible agency will provide additional instructions.
9, 10, and 12 - The responsible agency will provide additional instructions.
13 Providing information on alternate routes and modes in as much detail as
possible, discussing why certain routes or modes were rejected and why it is
necessary to cross Federal lands will assist the agency(ies) in processing your
application and reaching a final decision. Include only reasonable alternate
routes and modes as related to current technology and economics.
14 The responsible agency will provide instructions.
15 Generally, a simple statement of the purpose of the proposal will be sufficient.
However, major proposals located in critical or sensitive areas may require
a full analysis with additional specific information. The responsible agency
will provide additional instructions.
16 through 19 - Providing this information in as much detail as possible will
assist the Federal agency(ies) in processing the application and reaching a
decision. When completing these items, you should use a sound judgment
in furnishing relevant information. For example, if the project is not near a
stream or other body of water, do not address this subject. The responsible
agency will provide additional instructions.
Application must be signed by the applicant or applicant’s authorized
representative.
If additional space is needed to complete any item, please put the information
on a separate sheet of paper and identify it as “Continuation of Item”.
(For supplemental, see page 4)
(SF-299, page 3)
U.S. Department of the Interior
FISH AND WILDLIFE SERVICE
Alaska Regional Office (Region 7)
Mailing/Physical Address:
1011 East Tudor Road
Anchorage, Alaska 99501
Telephone: 907-271-5011
Note: Filings with any Department of the Interior agency may be filed with any
office noted above or with the:
U.S. Department of the Interior
OFFICE OF ENVIRONMENTAL POLICY AND COMPLIANCE
Alaska Regional Office (Anchorage)
Regional Environmental Officer
1689 C Street, Room 119
Anchorage, Alaska 99501
Telephone: (907) 271-5011
U.S. Department of Transportation
FEDERAL AVIATION ADMINISTRATION
Alaska Regional Office (Anchorage)
222 West 7th Avenue, #14
Anchorage, Alaska 99513
Telephone: 907-271-5269
SUPPLEMENTAL
ATTACHED FILED*
CHECK APPROPRIATE
BLOCK
NOTE: The responsible agency(ies) will provide additional instructions
I
- PRIVATE CORPORATIONS
a. Articles of Incorporation
b. Corporation Bylaws
c. A certification from the State showing the corporation is in good standing and is entitled to operate within the State.
d. Copy of resolution authorizing filing
e. The name and address of each shareholder owning 3 percent or more of the shares, together with the number and percentage of any
class of voting shares of the entity which such shareholder is authorized to vote and the name and address of each affiliate of the entity
together with, in the case of an affiliate controlled by the entity, the number of shares and the percentage of any class of voting stock of
that affiliate owned, directly or indirectly, by that entity, and in the case of an affiliate which controls that entity, the number of shares
and the percentage of any class of voting stock of that entity owned, directly or indirectly, by the affiliate.
f. If application is for an oil or gas pipeline, describe any related right-of-way or temporary use permit applications, and identify
previous applications
g. If application is for an oil and gas pipeline, identify all Federal lands by agency impacted by proposal.
II - PUBLIC CORPORATIONS
III - PARTNERSHIP OR OTHER UNINCORPORATED ENTITY
a. Copy of law forming corporation
b. Proof of organization
c. Copy of Bylaws
d. Copy of resolution authorizing filing
a. Articles of association, if any
b. If one partner is authorized to sign, resolution authorizing action is
c.
Name and address of each participant, partner, association, or other
d.
If application is for an oil or gas pipeline, provide information required by Item “I-f” and “I-g” above.
e. If application is for an oil or gas pipeline, provide information required by Item “I-f” and “I-g” above.
* If the required information is already filed with the agency processing this application and is current, check block entitled “Filed.” Provide the file identification
information (e.g., number, date, code, name). If not on file or current, attach the requested information.
(Continued on page 5)
(SF-299, page 4)
NOTICES
NOTE: This applies to the Department of the Interior/Bureau of Land Management (BLM).
The Privacy Act of 1974 provides that you be furnished with the following information in connection with the
information provided by this application for an authorization.
AUTHORITY: 16 U.S.C. 310 and 5 U.S.C. 301.
PRINCIPAL PURPOSE: The primary uses of the records are to facilitate the (1) processing of claims or
applications; (2) recordation of adjudicative actions; and (3) indexing of documentation in case files supporting
administrative actions.
ROUTINE USES: BLM and the Department of the Interior (DOI) may disclose your information on this form: (1) to
appropriate Federal agencies when concurrence or supporting information is required prior to granting or acquiring a
right or interest in lands or resources; (2) to members or the public who have a need for the information that is
maintained by BLM for public record; (3) to the U.S. Department of Justice, court, or other adjudicative body when
DOI determines the information is necessary and relevant to litigation; (4) to appropriate Federal, State, local, or
foreign agencies responsible for investigating, prosecuting violation, enforcing, or implementing this statute,
regulation, or order; and (5) to a congressional office when you request the assistance of the Member of Congress in
writing.
EFFECT OF NOT PROVIDING THE INFORMATION: Disclosing this information is necessary to receive or
maintain a benefit. Not disclosing it may result in rejecting the application.
The Paperwork Reduction Act of 1995 requires us to inform you that:
The Federal agencies collect this information from applicants requesting right-of-way, permit, license, lease, or
certifications for the use of Federal Lands.
Federal agencies use this information to evaluate your proposal.
No Federal agency may request or sponsor and you are not required to respond to a request for information which
does not contain a currently valid OMB Control Number.
BURDEN HOURS STATEMENT: The public burden for this form is estimated at 25 hours per response including
the 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 this form to: U.S. Department of the Interior, Bureau
of Land Management (1004-0189), Bureau Information Collection Clearance Officer (WO-630) 1849 C Street,
N.W., Mail Stop 401 LS, Washington, D.C. 20240.
A reproducible copy of this form may be obtained from the Bureau of Land Management, Division of Lands, Realty and
Cadastral urvey, 1620 L Street, N.W., Rm. 1000 LS, Washington, D.C. 20036. S
(SF – 299, page 5)
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