Attch_1k_-_LAAFB_SHIP_Requirements.pdf

This form is for the purposes of compliance with Section 106 of the National Historic Preservation Act of 1966, as amended.

(To be completed by Cultural Resources Staff only)

Submittal Date ______________ Project No. ______________________ � local CRM / � SHPO

Approved by _____________________________________________ Date____________ Any stipulations for approval shall be noted at the end of this form.

PART I

A. GENERAL INFORMATION

Project Title Project Location Building Number Major / Minor Work Order # Proposed Start Date Proposed Completion Date Project Manager / Title Department Phone Number Fax Number Mobile Number Email Address

B. PURPOSE AND NEED

Describe below the reason for proposing the project at this time and what the project hopes to accomplish.

C. WORK PLAN SPECIFICS

Describe below how the project would be implemented. Be as specific as possible about dates and methods. The form must include a project location map, photographs, and the following as appropriate: site plans, design and/or construction drawings, /msds cut sheets, other graphics.

FA4610-17-R-0002

Attachment 1k

PART II

“Yes” answers must be accompanied by an explanation of how the potential impact will be avoided. Justify “No” answers with an explanation when needed.

If implemented, could the project:

1. Affect a known historic property, an archeologically sensitive area, cultural landscape or other National Register of Historic Places listed or eligible resource/ If unknown, consult the Historic Compliance Coordinator

Yes / No

Explain:

2. Destroy, remove or replace historic fabric? Yes / No

3. Introduce, reintroduce or remove non-historic elements (physical, visible, audible, atmospheric) of a historic structure or environment? Yes / No

4. Cause deterioration of historic fabric, terrain or setting? Yes / No

5. Inhibit surface water drainage, alter the landscape topography, lead to increased runoff or erosion or compromise slope stability? Yes / No

6. Block an existing view, be visually intrusive or contribute to a degraded visual condition? Yes / No

Stipulations for approval (if any):

FA4610-17-R-0002

Attachment 1k