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U.S. Department of Transportation |
Report No.
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| Sheet No. 1 of _____ | |||||||||||||||||||||
Disaster No. CA
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Applicant |
County |
Incident Date (mm/dd/yy): |
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Location of Damage: Per Site or Per Mile (circle on) Name of Road Bridge __________________________________________ Begin ___________________ End ______________ PM Total Feet ___________ |
Federal-Aid Highway? | ||||||||||||||||||||
| ____ Yes (if no, ineligible for ER) | |||||||||||||||||||||
| Map No. __________ | |||||||||||||||||||||
Caltrans Work Order No(s): _____________________________________ |
Forest Highway System? | ||||||||||||||||||||
| Road/ Bridge Data | Bridge No. ________ | Type | ____ Yes (Possible ERFO) | ||||||||||||||||||
| Traveled Way | Width ___________ | Type (circle one) | PCC/ AC/ Gravel | Hwy. No. _________ | |||||||||||||||||
| Shoulder: | Width ___________ | Type (circle one) | PCC/ AC/ Gravel | State/Local Route No. |
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| Description of Damage: | ADT (Existing) | ||||||||||||||||||||
Photos |
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| COST ESTIMATE | |||||||||||||||||||||
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| Type of Repair | Decription of Work | Summary of Cost | |||||||||||||||||||
| Emergency Opening | Emergency Opening (EO) TO DATE) | ||||||||||||||||||||
_______ State Forces _______ Local Forces _______ Contract _______ EA/Contract # |
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| Emergency Opening (EO) WORK REMAINING | |||||||||||||||||||||
________ State Forces ________ Local Forces _________ Contract _______ EA/Contract # |
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| Subtotal Emergency Opening | $ ______________ | ||||||||||||||||||||
| Permanent Restoration |
PERMANENT RESTORATION (PR) | ||||||||||||||||||||
Recommended Method of Work: |
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________ State Forces ________ Local Forces _________ Contract |
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| NOTE: PRIOR AUTHORIZATION (APPROVED E -76) IS REQUIRED TO PROCEED WITH PERMANENT RESTORATION | Subtotal Permanent Restoration | $ ______________ | |||||||||||||||||||
Environmental Clearance: |
EO |
PR |
Preliminary Engineering (10% of PR) | $ ______________ | |||||||||||||||||
| Categorical | ______________ | Environmental clearance is conducted through normal Fed.-aid project procedures. | Construction Engineering (15% of PR) | $ ______________ | |||||||||||||||||
| Further Environmental Study | ______________ | Right of Way Acquisition |
$ ______________ | ||||||||||||||||||
EO Clearance signature/date: |
Total Estimated Cost (EO +PR+PE+CE+R/W) |
$ ______________ | |||||||||||||||||||
Stewardship: _____ State Authorized (E) ______ Full Oversight (N) |
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| Recommendation: | ______ Eligible | _______ Ineligible | FHWA Engineer* | Date | |||||||||||||||||
| Concurrence: | ______ Yes | _______ No | State Engineer | Date | |||||||||||||||||
| Concurrence: | ______ Yes | _______ No | Local Agency Engineer | Date | |||||||||||||||||
FHWA DA Form (CA Rev 01/04/07)
 California Division | U.S. Department of Transportation Federal Highway Administration |