RESURFACING PLANS CERTIFICATION OF SCOPE OF WORK

TO:	TDOT.Env.AirNoise@tn.gov

TDOT.Env.CulturalResources@tn.gov

TDOT.Env.Ecology@tn.gov

TDOT.Env.HazmatOffice@tn.gov

TDOT.Env.NEPA@tn.gov

TDOT.Env.Permits@tn.gov

TDOT.MultimodalPlanning@tn.gov

FROM:

DATE:	Click here to enter a date.

SUBJECT:	COUNTY:

PIN:

PROJECT NO.

PROJECT DESCRIPTION:

PROJECT LENGTH (MILE):

Disturbed Acreage:	☐ Less Than 1 Acre ☐1 Acre or Greater

R.O.W. or Easements Required*:	☐Yes	☐No

*For Fee Simple Acquisitions, answer Yes. If within easement (no acquisition required due to previous agreement), answer No.

The subject resurfacing project is limited to the following items:

☐	Cold planning existing asphalt

☐	Installation of rumble strips / stripes

☐	Pavement markings

☐	Raised pavement markings

☐	Resurfacing

☐	Safety edge

☐	Sign replacement or upgrades

Safety Upgrades

☐ Add 2 ft. wide shoulder at locations where there is no existing shoulder

☐ Center line rumble stripe

☐ End terminal (Type 38, 21, and 13) remove, upgrade, or new installation

☐	Existing guardrail height adjustment

☐	Improve roadway superelevation (no grading or pavement reconstruction)

☐	Install breakaway sign support hardware

☐	Install earth pad

☐	Install new or upgrade existing to self-restoring / low maintenance crash cushion

☐	Installation of skid resistant surfaces

☐	Remove, install, and/or repair substandard bridge rail

☐	Remove, relocate, or delineate roadside obstacles (i.e. trees) located within the clear zone

☐	Sight distance correction (intersection and/or stopping)

Drainage Maintenance

☐	Clean/ reshape roadside ditch

☐	Install a drainage pipe safety head wall (parallel or perpendicular) if inlet or outlet located	within the clear zone

☐	Stabilize eroded channel/bank

Pedestrian Accessibility and Bicycle Accommodation

☐	Install curb ramps

☐	Install curb ramps on side roads to maintain continuity/accessibility

Refer to TDOT Long Range Multimodal Transportation Plan (Contact Bicycle/Pedestrian Coordinator) if the subject highway is planned to incorporate the following:

☐	Pavement marking and signing for bike route

☐	Pavement marking and signing for bike lane

Work Zone Safety

☐	Detour

☐	Significant project determination

☐	Temporary traffic control

☐	Other: _____________________________

Attachments

☐	Title Sheet

☐	Bridge Recommendations (required)

I certify that the scope of the subject resurfacing and safety project is limited to the items listed above.

____________________________________	___________	Regional Resurfacing Coordinator	Date

____________________________________	___________

Civil Engineering Manager 1	Date

If additional items are added to the scope of work during plans development, complete the section below and resubmit to the Environmental Office.

ADDENDUM TO SCOPE OF WORK

The following has been added to the original scope of work for the subject resurfacing project:

______________________________________________________________________

____________________________________	___________

Regional Resurfacing Coordinator	Date

____________________________________	___________

Civil Engineering Manager 1	Date