Preservation Form

Free Fillable Section 106 Review

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25 fieldscompliance

Project Information

Project Name / Undertaking Title*

Recorder Name*

Review Date*

Federal Agency*

Agency Project Number

SHPO / THPO Office

Undertaking Description

Undertaking Type*

Federal Nexus*

Undertaking Description*

Undertaking Location

Area of Potential Effects (APE)

APE Description*

Direct Effects Area

Indirect Effects Area

APE Justification

Historic Properties Within or Adjacent to APE

Determination of Effect

Determination of Effect*

Applicable Adverse Effect Criteria (36 CFR 800.5)

Physical destruction or damageAlteration inconsistent with Secretary of Interior StandardsRemoval from locationChange in use or physical features of settingIntroduction of incompatible visual elementsNeglect leading to deteriorationTransfer / sale / lease without protective covenants

Effects Description*

Avoidance & Minimization Measures

Consulting Party Notes

Consulting Parties

Tribal Consultation RequiredTribal Consultation Required

SHPO Concurrence Status

Consulting Party Notes

Resolution Measures / Stipulations

Photos

Location

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