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FHWA DA Form (CA Rev 01/04/07) Report No. U.S. Department of Transportation - - - Federal Highway Administration - California Division Sheet No. 1 of Damage Assessment Form (DAF) - Title 23 Disaster No. CA - Applicant County Incident date (mm/dd/yy) Inspection date

Location of Damage : Per Site or Per Mile (circle one) Federal-Aid Highway?

Name of Road/Bridge Yes (if no, ineligible for ER)

Begin ______End ______PM Total Feet ______Map No. Caltrans Work Order No(s): Forest Highway System? Yes (Possible ERFO) Road/Bridge Data Bridge No. Type Traveled Way: Width Type (circle one) PCC / AC / Gravel Hwy. No. Shoulder: Width Type (circle one) PCC / AC / Gravel State/Local Route No.

Description of Damage: ADT (Existing)

Photos Roll /Disk # Picture # COST ESTIMATE g

n Type of Repair Description of Work Summary Cost i n

e EMERGENCY OPENING (EO) TO DATE p O

____ State Forces Local Forces y c n e

g ____Contract EA/Contract # ______r e EMERGENCY______OPENING (EO) m

E WORK REMAINING State Forces Local Forces

____ Contract EA/Contract #______Subtotal Emergency Opening $ ______n

o PERMANENT RESTORATION (PR) i t

a Recommended Method of Work: r o t s e R

t _____ State Forces Local Forces n e n a ____ Contract m r e P

NOTE: PRIOR AUTHORIZATION (APPROVED E-76) IS REQUIRED Subtotal Permanent Restoration $ ______TO PROCEED WITH PERMANENT RESTORATION Environmental Clearance: EO PR Preliminary Engineering (10% of PR) Categorical Exclusion Environmental $ ______clearance is Construction Engineering (15% of PR) Further Environmental Study conducted $ ______EO Clearance signature/date: through normal Right-of-Way Acquisition $ ______Fed.-aid project procedures.

Stewardship: TOTAL ESTIMATED COST $ ______State Authorized (E) Full Oversight (N) (EO+PR+PE+CE+R/W) FHWA Engineer* Date Recommendation: Eligible Ineligible State Engineer Date Concurrence: Yes No Local Agency Engineer Date Concurrence: Yes No Original: Caltrans District Copies: FHWA, Division of Local Assistance (local roads), Federal Resources (state hwy), HA23 Coordinator. (state hwy) *Write “N/A” in FHWA signature block if the project has no Federal ER funding (state-only emergency) or Federal ER funding (delegated down to the State).

FHWA DA Form (CA Rev 01/04/07) U.S. Department of Transportation Report No. Federal Highway Administration Sheet No. of California Division Applicant Damage Assessment Form (DAF) Title 23, Federal-Aid Highways

Quantity Unit Labor, Materials, and Equipment Unit Price Cost

FHWA DA Form (CA Rev 01/04/07) U.S. Department of Transportation Report No. Federal Highway Administration Sheet No. of California Division Applicant Damage Assessment Form (DAF) Title 23, Federal-Aid Highways

Sketches and/or Narrative

Miscellaneous FHWA Approvals Reflects available information for contracts at the time of DAF preparation. A revised DAF is not required for changes – use normal Federal-aid procedures to adjust for changes with approval (per Stewardship) based on documented justification.

Describe:

FHWA DA Form (CA Rev 01/04/07)