Control Section Job Number (CSJ): <Enter CSJ Number>
District/County: <Enter Name of District/County>
Property ID: <Enter Property ID>
Property Name: <Enter Name of Property>
The following checklist was developed as a tool to assist in streamlining the Section 4(f) Exceptionprocess and toensure that all necessary information is documented in the File of Record (ECOS).
Note: This checklist is not all-inclusive and should be modified as appropriate with ENV approval.
For each of the following steps and/or items, check the appropriate box in the columns on the left.
Check one box ONLY.
I. Section 4(f) Defining Criteria for Historic Properties
Yes / No
A.Is the property listed or eligible for the NRHP or NHL?
II. Establishing Section 4(f) Use of the Property
Yes / No
A.Does the project require a temporary use (i.e. temporary easement, construction easement, etc.)?
III. Establishing Section 4(f) ExceptionEligibility
Yes / No
A.Was it determined that the duration of use will be less than thetime needed for construction of the project and there will be no change in ownership?
B.Was it determined that the scope of the work would be minor resulting in minimal changes to the property?
C.Was it determined that no significant features of the property would be adversely affected?
D.Was it determined that the occupied segments of the propertywould be returned to their as-found conditions or better?
E.Did the Official with Jurisdiction agree that the property was significant and that the proposed project meets ALL conditions of items in Sections I, II and III above?
IV. Documentation
The following MUST be attached to this checklist to ensure proper documentation of the
Section 4(f) Exception:
1.Brief project description with explanation of how the property will be used.
2.A detailed map of the Section 4(f) property including:
a. Current and proposed ROW
b. Property boundaries
c. Existing and planned facilities
3.Concurrence letter with the Official with Jurisdiction
V. TxDOT Approval Signatures
ENV Technical Expert Reviewer Certification
I reviewed this checklist and all attached documentation and confirm that the above property and proposed project meet the requirements of 23 CFR 774 for a Section 4(f) Exception finding.
______
ENV Personnel NameDate
TxDOT-ENV Section 4(f) ExceptionFinal Approval
Based upon the above considerations, this Section 4(f) Exception satisfies the requirements
of 23 CFR 774.
______
TxDOT-ENV, PD Director or designeeDate
The following table shows the revision history for this document.
Revision HistoryEffective Date
Month, Year / Reason for and Description of Change
August 2014 / Version 1 release
StandardVersion 1
TxDOT Environmental Affairs Division 815.02.CHK
Release Date: August 2014Page 1 of 4