+--------------+---+-------+------+---------------+---+--------------------+
| **SCOUR      |   |       |      |               |   |                    |
| CRITICAL     |   |       |      |               |   |                    |
| BRIDGE -     |   |       |      |               |   |                    |
| PLAN OF      |   |       |      |               |   |                    |
| ACTION**     |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **1. GENERAL |   |       |      |               |   |                    |
| I            |   |       |      |               |   |                    |
| NFORMATION** |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Structure  |   | **    |      |               |   | **Waterway:**      |
| number:**    |   | City, |      |               |   |                    |
|              |   | Co    |      |               |   | [                  |
| [     ]      |   | unty, |      |               |   |      ]{.underline} |
| {.underline} |   | Sta   |      |               |   |                    |
|              |   | te:** |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   | [     |      |               |   |                    |
|              |   |   ]{. |      |               |   |                    |
|              |   | under |      |               |   |                    |
|              |   | line} |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Structure  |   | **    |      |               |   | **Owner:**         |
| name:**      |   | State |      |               |   |                    |
|              |   | hi    |      |               |   | [                  |
| [     ]      |   | ghway |      |               |   |      ]{.underline} |
| {.underline} |   | or    |      |               |   |                    |
|              |   | fac   |      |               |   |                    |
|              |   | ility |      |               |   |                    |
|              |   | carri |      |               |   |                    |
|              |   | ed:** |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   | [     |      |               |   |                    |
|              |   |   ]{. |      |               |   |                    |
|              |   | under |      |               |   |                    |
|              |   | line} |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Year       | * |       |      | **Bridge      |   |                    |
| built:**     | * |       |      | replacement   |   |                    |
| [    ]       | Y |       |      | plans (if     |   |                    |
| {.underline} | e |       |      | scheduled):** |   |                    |
|              | a |       |      | [             |   |                    |
|              | r |       |      | ]{.underline} |   |                    |
|              | r |       |      |               |   |                    |
|              | e |       |      | **Anticipated |   |                    |
|              | b |       |      | opening       |   |                    |
|              | u |       |      | date:**       |   |                    |
|              | i |       |      | [             |   |                    |
|              | l |       |      | ]{.underline} |   |                    |
|              | t |       |      |               |   |                    |
|              | : |       |      |               |   |                    |
|              | * |       |      |               |   |                    |
|              | * |       |      |               |   |                    |
|              | [ |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              | ] |       |      |               |   |                    |
|              | { |       |      |               |   |                    |
|              | . |       |      |               |   |                    |
|              | u |       |      |               |   |                    |
|              | n |       |      |               |   |                    |
|              | d |       |      |               |   |                    |
|              | e |       |      |               |   |                    |
|              | r |       |      |               |   |                    |
|              | l |       |      |               |   |                    |
|              | i |       |      |               |   |                    |
|              | n |       |      |               |   |                    |
|              | e |       |      |               |   |                    |
|              | } |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Structure  |   |       |      |               |   |                    |
| type:**      |   |       |      |               |   |                    |
| Bridge       |   |       |      |               |   |                    |
| Culvert      |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **Structure  |   |       |      |               |   |                    |
| size and     |   |       |      |               |   |                    |
| de           |   |       |      |               |   |                    |
| scription:** |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Fo         |   |       |      |               |   |                    |
| undations:** |   |       |      |               |   |                    |
| Known, type: |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
| Depth:       |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
| Unknown      |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Subsurface |   |       |      |               |   |                    |
| soil         |   |       |      |               |   |                    |
| information  |   |       |      |               |   |                    |
| (*check all  |   |       |      |               |   |                    |
| that         |   |       |      |               |   |                    |
| apply*):**   |   |       |      |               |   |                    |
| Non-cohesive |   |       |      |               |   |                    |
| Cohesive     |   |       |      |               |   |                    |
| Rock         |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Bridge     |   |       | *    |               | * |                    |
| ADT:**       |   |       | *Yea |               | * |                    |
| [     ]      |   |       | r/AD |               | % |                    |
| {.underline} |   |       | T:** |               | T |                    |
|              |   |       | [    |               | r |                    |
|              |   |       |    ] |               | u |                    |
|              |   |       | {.un |               | c |                    |
|              |   |       | derl |               | k |                    |
|              |   |       | ine} |               | s |                    |
|              |   |       |      |               | : |                    |
|              |   |       |      |               | * |                    |
|              |   |       |      |               | * |                    |
|              |   |       |      |               | [ |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
|              |   |       |      |               | ] |                    |
|              |   |       |      |               | { |                    |
|              |   |       |      |               | . |                    |
|              |   |       |      |               | u |                    |
|              |   |       |      |               | n |                    |
|              |   |       |      |               | d |                    |
|              |   |       |      |               | e |                    |
|              |   |       |      |               | r |                    |
|              |   |       |      |               | l |                    |
|              |   |       |      |               | i |                    |
|              |   |       |      |               | n |                    |
|              |   |       |      |               | e |                    |
|              |   |       |      |               | } |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Does the   |   |       |      |               |   |                    |
| bridge       |   |       |      |               |   |                    |
| provide      |   |       |      |               |   |                    |
| service to   |   |       |      |               |   |                    |
| emergency    |   |       |      |               |   |                    |
| facilities   |   |       |      |               |   |                    |
| and/or an    |   |       |      |               |   |                    |
| evacuation   |   |       |      |               |   |                    |
| route        |   |       |      |               |   |                    |
| (Y/N)?**     |   |       |      |               |   |                    |
| [    ]       |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **If so,     |   |       |      |               |   |                    |
| describe:**  |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **2.         |   |       |      |               |   |                    |
| RE           |   |       |      |               |   |                    |
| SPONSIBILITY |   |       |      |               |   |                    |
| FOR POA**    |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **Author(s)  |   |       |      |               |   |                    |
| of POA       |   |       |      |               |   |                    |
| (name,       |   |       |      |               |   |                    |
| title,       |   |       |      |               |   |                    |
| agency/o     |   |       |      |               |   |                    |
| rganization, |   |       |      |               |   |                    |
| telephone,   |   |       |      |               |   |                    |
| pager,       |   |       |      |               |   |                    |
| email):**    |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| [            |   |       |      |               |   |                    |
|  ]           |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **Date:      |   |       |      |               |   |                    |
| [     ]{.    |   |       |      |               |   |                    |
| underline}** |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **           |   |       |      |               |   |                    |
| Concurrences |   |       |      |               |   |                    |
| on POA       |   |       |      |               |   |                    |
| (name,       |   |       |      |               |   |                    |
| title,       |   |       |      |               |   |                    |
| agency/o     |   |       |      |               |   |                    |
| rganization, |   |       |      |               |   |                    |
| telephone,   |   |       |      |               |   |                    |
| pager,       |   |       |      |               |   |                    |
| email):**    |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| [            |   |       |      |               |   |                    |
|     ]        |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **POA        |   |       |      |               |   |                    |
| updated by   |   |       |      |               |   |                    |
| (name,       |   |       |      |               |   |                    |
| title,       |   |       |      |               |   |                    |
| agency,      |   |       |      |               |   |                    |
| orga         |   |       |      |               |   |                    |
| nization):** |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
| **Date of    |   |       |      |               |   |                    |
| update:**    |   |       |      |               |   |                    |
| [   ]        |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **Items      |   |       |      |               |   |                    |
| update:**    |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **POA to be  |   |       |      |               |   |                    |
| updated      |   |       |      |               |   |                    |
| every**      |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
| **months by  |   |       |      |               |   |                    |
| (name,       |   |       |      |               |   |                    |
| title,       |   |       |      |               |   |                    |
| agency       |   |       |      |               |   |                    |
| /organizatio |   |       |      |               |   |                    |
| n):**[     ] |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
|              |   |       |      |               |   |                    |
| **Date of    |   |       |      |               |   |                    |
| next         |   |       |      |               |   |                    |
| upda         |   |       |      |               |   |                    |
| te:**[     ] |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **3. SCOUR   |   |       |      |               |   |                    |
| VUL          |   |       |      |               |   |                    |
| NERABILITY** |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **a. Current |   |       |      |               |   |                    |
| Item 113     |   |       |      |               |   |                    |
| Code:** 3 2  |   |       |      |               |   |                    |
| 1 Other:     |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **b. Source  |   |       |      |               |   |                    |
| of Scour     |   |       |      |               |   |                    |
| Critical     |   |       |      |               |   |                    |
| Code:**      |   |       |      |               |   |                    |
| Observed     |   |       |      |               |   |                    |
| Assessment   |   |       |      |               |   |                    |
| Calculated   |   |       |      |               |   |                    |
| Other:       |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **c. Scour   |   |       |      |               |   |                    |
| Evaluation   |   |       |      |               |   |                    |
| Summary:**   |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+
| **d. Scour   |   |       |      |               |   |                    |
| History:**   |   |       |      |               |   |                    |
| [     ]      |   |       |      |               |   |                    |
| {.underline} |   |       |      |               |   |                    |
+--------------+---+-------+------+---------------+---+--------------------+

+---------------+------------------+----------------+----------------+
| **4.          |                  |                |                |
| RECOMMENDED   |                  |                |                |
| ACTION(S)     |                  |                |                |
| (see Sections |                  |                |                |
| 6 and 7)**    |                  |                |                |
+---------------+------------------+----------------+----------------+
| *             |                  |                |                |
| *[Recommended |                  |                |                |
| ]{.underline} |                  |                |                |
| [             |                  |                |                |
| Implemented]{ |                  |                |                |
| .underline}** |                  |                |                |
|               |                  |                |                |
| **a.          |                  |                |                |
| Increased     |                  |                |                |
| Inspection    |                  |                |                |
| Frequency**   |                  |                |                |
| Yes No Yes No |                  |                |                |
|               |                  |                |                |
| **b. Fixed    |                  |                |                |
| Monitoring    |                  |                |                |
| Device(s)**   |                  |                |                |
| Yes No Yes No |                  |                |                |
|               |                  |                |                |
| **c. Flood    |                  |                |                |
| Monitoring    |                  |                |                |
| Program** Yes |                  |                |                |
| No Yes No     |                  |                |                |
|               |                  |                |                |
| **d.          |                  |                |                |
| Hydraul       |                  |                |                |
| ic/Structural |                  |                |                |
| Coun          |                  |                |                |
| termeasures** |                  |                |                |
| Yes No Yes No |                  |                |                |
+---------------+------------------+----------------+----------------+
| **5. NBI      |                  |                |                |
| CODING        |                  |                |                |
| INFORMATION** |                  |                |                |
+---------------+------------------+----------------+----------------+
|               |                  | **[Current]    | **[Previous]   |
|               |                  | {.underline}** | {.underline}** |
+---------------+------------------+----------------+----------------+
| **Inspection  |                  |                | **     **      |
| date**        |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Item 113    |                  | **  **         | **  **         |
| Scour         |                  |                |                |
| Critical**    |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Item 60     |                  | **  **         | **  **         |
| S             |                  |                |                |
| ubstructure** |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Item 61     |                  | **  **         | **  **         |
| Channel &     |                  |                |                |
| Channel       |                  |                |                |
| Protection**  |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Item 71     |                  | **  **         | **  **         |
| Waterway      |                  |                |                |
| Adequacy**    |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Comments:   |                  | **[     ]      | **[     ]      |
| (drift, scour |                  | {.underline}** | {.underline}** |
| holes, etc. - |                  |                |                |
| depict in     |                  |                |                |
| sketches in   |                  |                |                |
| Section 10)** |                  |                |                |
+---------------+------------------+----------------+----------------+
| **6.          |                  |                |                |
| MONITORING    |                  |                |                |
| PROGRAM**     |                  |                |                |
+---------------+------------------+----------------+----------------+
| > **Regular   |                  |                |                |
| > Inspection  |                  |                |                |
| > Program**   |                  |                |                |
| > w/surveyed  |                  |                |                |
| > cross       |                  |                |                |
| > sections    |                  |                |                |
| >             |                  |                |                |
| > Items to    |                  |                |                |
| > Watch:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **Increased |                  |                |                |
| > Inspection  |                  |                |                |
| > Frequency   |                  |                |                |
| > of          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > mo.**       |                  |                |                |
| > w/surveyed  |                  |                |                |
| > cross       |                  |                |                |
| > sections    |                  |                |                |
| >             |                  |                |                |
| > Items to    |                  |                |                |
| > Watch:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| >             |                  |                |                |
|  **Underwater |                  |                |                |
| > Inspection  |                  |                |                |
| > Required**  |                  |                |                |
| >             |                  |                |                |
| > Items to    |                  |                |                |
| > Watch:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **Increased |                  |                |                |
| > Underwater  |                  |                |                |
| > Inspection  |                  |                |                |
| > Frequency   |                  |                |                |
| > of          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > mo.**       |                  |                |                |
| >             |                  |                |                |
| > Items to    |                  |                |                |
| > Watch:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **Fixed     |                  |                |                |
| > Monitoring  |                  |                |                |
| > Device(s)** |                  |                |                |
| >             |                  |                |                |
| > Type of     |                  |                |                |
| > Instrument: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| >             |                  |                |                |
|  Installation |                  |                |                |
| >             |                  |                |                |
|  location(s): |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Sample      |                  |                |                |
| > Interval:   |                  |                |                |
| > 30 min. 1   |                  |                |                |
| > hr. 6 hrs.  |                  |                |                |
| > 12 hrs.     |                  |                |                |
| > Other:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Frequency   |                  |                |                |
| > of data     |                  |                |                |
| > download    |                  |                |                |
| > and review: |                  |                |                |
| > Daily       |                  |                |                |
| > Weekly      |                  |                |                |
| > Monthly     |                  |                |                |
| > Other       |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Scour alert |                  |                |                |
| >             |                  |                |                |
|  elevation(s) |                  |                |                |
| > for each    |                  |                |                |
| > p           |                  |                |                |
| ier/abutment: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Scour       |                  |                |                |
| > critical    |                  |                |                |
| >             |                  |                |                |
| elevations(s) |                  |                |                |
| > for each    |                  |                |                |
| > p           |                  |                |                |
| ier/abutment: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Survey      |                  |                |                |
| > ties:       |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Criteria of |                  |                |                |
| > termination |                  |                |                |
| > for fixed   |                  |                |                |
| > monitoring: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **Flood     |                  |                |                |
| > Monitoring  |                  |                |                |
| > Program**   |                  |                |                |
| >             |                  |                |                |
| > Type:       |                  |                |                |
| > Visual      |                  |                |                |
| > inspection  |                  |                |                |
| >             |                  |                |                |
| > Instrument  |                  |                |                |
| > (*check all |                  |                |                |
| > that        |                  |                |                |
| > apply*):    |                  |                |                |
| >             |                  |                |                |
| > Portable    |                  |                |                |
| > Geophysical |                  |                |                |
| > Sonar       |                  |                |                |
| > Other:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Flood       |                  |                |                |
| > monitoring  |                  |                |                |
| > required:   |                  |                |                |
| > Yes No      |                  |                |                |
| >             |                  |                |                |
| > Flood       |                  |                |                |
| > monitoring  |                  |                |                |
| > event       |                  |                |                |
| > defined by  |                  |                |                |
| > (*check all |                  |                |                |
| > that        |                  |                |                |
| > apply*):    |                  |                |                |
| >             |                  |                |                |
| > Discharge   |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > Stage       |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Elev.       |                  |                |                |
| > measured    |                  |                |                |
| > from        |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > Rainfall    |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > (in/mm) per |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > (hour)      |                  |                |                |
| >             |                  |                |                |
| > Flood       |                  |                |                |
| > forecasting |                  |                |                |
| >             |                  |                |                |
|  information: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Flood       |                  |                |                |
| > warning     |                  |                |                |
| > system:     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Frequency   |                  |                |                |
| > of flood    |                  |                |                |
| > monitoring: |                  |                |                |
| > 1 hr. 3     |                  |                |                |
| > hrs. 6 hrs. |                  |                |                |
| > Other:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Post-flood  |                  |                |                |
| > monitoring  |                  |                |                |
| > required:   |                  |                |                |
| > No Yes,     |                  |                |                |
| > within      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > days        |                  |                |                |
| >             |                  |                |                |
| > Frequency   |                  |                |                |
| > of          |                  |                |                |
| > post-flood  |                  |                |                |
| > monitoring: |                  |                |                |
| > Daily       |                  |                |                |
| > Weekly      |                  |                |                |
| > Monthly     |                  |                |                |
| > Other:      |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > Criteria    |                  |                |                |
| > for         |                  |                |                |
| > termination |                  |                |                |
| > of flood    |                  |                |                |
| > monitoring: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Criteria    |                  |                |                |
| > for         |                  |                |                |
| > termination |                  |                |                |
| > of          |                  |                |                |
| > post-flood  |                  |                |                |
| > monitoring: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Scour alert |                  |                |                |
| >             |                  |                |                |
|  elevation(s) |                  |                |                |
| > for each    |                  |                |                |
| > p           |                  |                |                |
| ier/abutment: |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| Scour         |                  |                |                |
| critical      |                  |                |                |
| elevation(s)  |                  |                |                |
| for each      |                  |                |                |
| p             |                  |                |                |
| ier/abutment: |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| *Note:        |                  |                |                |
| Additional    |                  |                |                |
| details for   |                  |                |                |
| action(s)     |                  |                |                |
| required may  |                  |                |                |
| be included   |                  |                |                |
| in Section    |                  |                |                |
| 8*.           |                  |                |                |
|               |                  |                |                |
| > Action(s)   |                  |                |                |
| > required if |                  |                |                |
| > scour alert |                  |                |                |
| > elevation   |                  |                |                |
| > detected    |                  |                |                |
| > (*include   |                  |                |                |
| >             |                  |                |                |
|  notification |                  |                |                |
| > and closure |                  |                |                |
| >             |                  |                |                |
| procedures*): |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Action(s)   |                  |                |                |
| > required if |                  |                |                |
| > scour       |                  |                |                |
| > critical    |                  |                |                |
| > elevation   |                  |                |                |
| > detected    |                  |                |                |
| > (*include   |                  |                |                |
| >             |                  |                |                |
|  notification |                  |                |                |
| > and closure |                  |                |                |
| >             |                  |                |                |
| procedures*): |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Agency and  |                  |                |                |
| department    |                  |                |                |
| responsible   |                  |                |                |
| for           |                  |                |                |
| monitoring:** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Contact     |                  |                |                |
| person        |                  |                |                |
| (*include     |                  |                |                |
| name, title,  |                  |                |                |
| telephone,    |                  |                |                |
| pager,        |                  |                |                |
| e-mail*):**   |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **7.          |                  |                |                |
| C             |                  |                |                |
| OUNTERMEASURE |                  |                |                |
| RECO          |                  |                |                |
| MMENDATIONS** |                  |                |                |
+---------------+------------------+----------------+----------------+
| *Prioritize   |                  |                |                |
| alternatives  |                  |                |                |
| below.        |                  |                |                |
| Include       |                  |                |                |
| information   |                  |                |                |
| on any        |                  |                |                |
| hydraulic,    |                  |                |                |
| structural or |                  |                |                |
| monitoring    |                  |                |                |
| coun          |                  |                |                |
| termeasures.* |                  |                |                |
|               |                  |                |                |
| > **Only      |                  |                |                |
| > monitoring  |                  |                |                |
| > required    |                  |                |                |
| > (see        |                  |                |                |
| > Section 6   |                  |                |                |
| > and Section |                  |                |                |
| > 10 --       |                  |                |                |
| > Attachment  |                  |                |                |
| > F)**        |                  |                |                |
| >             |                  |                |                |
| > Estimated   |                  |                |                |
| > cost        |                  |                |                |
| > \$[         |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **Structu   |                  |                |                |
| ral/hydraulic |                  |                |                |
| > coun        |                  |                |                |
| termeasures** |                  |                |                |
| >             |                  |                |                |
|  **considered |                  |                |                |
| > (see        |                  |                |                |
| > Section 10, |                  |                |                |
| > Attachment  |                  |                |                |
| > F):**       |                  |                |                |
| >             |                  |                |                |
| > **[Priority |                  |                |                |
| > Ranking]{   |                  |                |                |
| .underline}** |                  |                |                |
| >             |                  |                |                |
|  **[Estimated |                  |                |                |
| > cost]{      |                  |                |                |
| .underline}** |                  |                |                |
| >             |                  |                |                |
| > **(1)**     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > \$          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **(2)**     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > \$          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **(3)**     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > \$          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **(4)**     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > \$          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > **(5)**     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > \$          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **Basis for   |                  |                |                |
| the selection |                  |                |                |
| of the        |                  |                |                |
| preferred     |                  |                |                |
| scour         |                  |                |                |
| coun          |                  |                |                |
| termeasure:** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **C           |                  |                |                |
| ountermeasure |                  |                |                |
| i             |                  |                |                |
| mplementation |                  |                |                |
| project       |                  |                |                |
| type:**       |                  |                |                |
|               |                  |                |                |
| > Proposed    |                  |                |                |
| >             |                  |                |                |
|  Construction |                  |                |                |
| > Project     |                  |                |                |
| > Maintenance |                  |                |                |
| > Project     |                  |                |                |
| >             |                  |                |                |
| > Programmed  |                  |                |                |
| > C           |                  |                |                |
| onstruction - |                  |                |                |
| > Project     |                  |                |                |
| > Lead        |                  |                |                |
| > Agency:     |                  |                |                |
| >             |                  |                |                |
| > Bridge      |                  |                |                |
| > Bureau Road |                  |                |                |
| > Design      |                  |                |                |
| > Other       |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **Agency and  |                  |                |                |
| department    |                  |                |                |
| responsible   |                  |                |                |
| for           |                  |                |                |
| c             |                  |                |                |
| ountermeasure |                  |                |                |
| program (if   |                  |                |                |
| different     |                  |                |                |
| from Section  |                  |                |                |
| 6 contact for |                  |                |                |
| m             |                  |                |                |
| onitoring):** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **Contact     |                  |                |                |
| person        |                  |                |                |
| (*include     |                  |                |                |
| name, title,  |                  |                |                |
| telephone,    |                  |                |                |
| pager,        |                  |                |                |
| e-mail*):**   |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **Target      |                  |                |                |
| design        |                  |                |                |
| completion    |                  |                |                |
| date:**       |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **Target      |                  |                |                |
| construction  |                  |                |                |
| completion    |                  |                |                |
| date:**       |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| **Co          |                  |                |                |
| untermeasures |                  |                |                |
| already       |                  |                |                |
| completed:**  |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **8. BRIDGE   |                  |                |                |
| CLOSURE       |                  |                |                |
| PLAN**        |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Scour       |                  |                |                |
| monitoring    |                  |                |                |
| criteria for  |                  |                |                |
| consideration |                  |                |                |
| of bridge     |                  |                |                |
| closure:**    |                  |                |                |
|               |                  |                |                |
| > Water       |                  |                |                |
| > surface     |                  |                |                |
| > elevation   |                  |                |                |
| > reaches     |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > at          |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| >             |                  |                |                |
| > Overtopping |                  |                |                |
| > road or     |                  |                |                |
| > structure   |                  |                |                |
| >             |                  |                |                |
| > Scour       |                  |                |                |
| > measurement |                  |                |                |
| > results /   |                  |                |                |
| > Monitoring  |                  |                |                |
| > device (See |                  |                |                |
| > Section 6)  |                  |                |                |
| >             |                  |                |                |
| > Observed    |                  |                |                |
| > structure   |                  |                |                |
| > movement /  |                  |                |                |
| > Settlement  |                  |                |                |
| >             |                  |                |                |
| > Discharge:  |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
| > cfs/cms     |                  |                |                |
| >             |                  |                |                |
| > Flood       |                  |                |                |
| > forecast:   |                  |                |                |
| > [           |                  |                |                |
| ]{.underline} |                  |                |                |
|               |                  |                |                |
| Other: Debris |                  |                |                |
| accumulation  |                  |                |                |
| Movement of   |                  |                |                |
| riprap/other  |                  |                |                |
| armor         |                  |                |                |
| protection    |                  |                |                |
|               |                  |                |                |
| Loss of road  |                  |                |                |
| embankment    |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Emergency   |                  |                |                |
| repair plans  |                  |                |                |
| (*include     |                  |                |                |
| source(s),    |                  |                |                |
| contact(s),   |                  |                |                |
| cost,         |                  |                |                |
| installation  |                  |                |                |
| di            |                  |                |                |
| rections*):** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Agency and  |                  |                |                |
| department    |                  |                |                |
| responsible   |                  |                |                |
| for           |                  |                |                |
| closure:**    |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Contact     |                  |                |                |
| persons       |                  |                |                |
| (name, title, |                  |                |                |
| agency/       |                  |                |                |
| organization, |                  |                |                |
| telephone,    |                  |                |                |
| pager,        |                  |                |                |
| email):**     |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Criteria    |                  |                |                |
| for           |                  |                |                |
| re-opening    |                  |                |                |
| the bridge:** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Agency and  |                  |                |                |
| person        |                  |                |                |
| responsible   |                  |                |                |
| for           |                  |                |                |
| re-opening    |                  |                |                |
| the bridge    |                  |                |                |
| after         |                  |                |                |
| inspection:** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **9. DETOUR   |                  |                |                |
| ROUTE**       |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Detour      |                  |                |                |
| route         |                  |                |                |
| description** |                  |                |                |
| (route        |                  |                |                |
| number,       |                  |                |                |
| from/to,      |                  |                |                |
| distance from |                  |                |                |
| bridge,       |                  |                |                |
| etc.) -       |                  |                |                |
| Include map   |                  |                |                |
| in Section    |                  |                |                |
| 10,           |                  |                |                |
| Attachment E. |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Bridges on  |                  |                |                |
| Detour        |                  |                |                |
| Route:**      |                  |                |                |
+---------------+------------------+----------------+----------------+
| Bridge Number | Waterway         | Sufficiency    | Item 113 Code  |
|               |                  | Rating/ Load   |                |
|               |                  | Limitations    |                |
+---------------+------------------+----------------+----------------+
|               |                  |                |                |
+---------------+------------------+----------------+----------------+
|               |                  |                |                |
+---------------+------------------+----------------+----------------+
|               |                  |                |                |
+---------------+------------------+----------------+----------------+
|               |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Traffic     |                  |                |                |
| control       |                  |                |                |
| equipment     |                  |                |                |
| (detour       |                  |                |                |
| signing and   |                  |                |                |
| barriers) and |                  |                |                |
| l             |                  |                |                |
| ocation(s):** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **Additional  |                  |                |                |
| c             |                  |                |                |
| onsiderations |                  |                |                |
| or critical   |                  |                |                |
| issues        |                  |                |                |
| (s            |                  |                |                |
| usceptibility |                  |                |                |
| to            |                  |                |                |
| overtopping,  |                  |                |                |
| limited       |                  |                |                |
| waterway      |                  |                |                |
| adequacy,     |                  |                |                |
| lane          |                  |                |                |
| restrictions, |                  |                |                |
| etc.) :**     |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **News        |                  |                |                |
| release,      |                  |                |                |
| other public  |                  |                |                |
| notice        |                  |                |                |
| (include      |                  |                |                |
| authorized    |                  |                |                |
| person(s),    |                  |                |                |
| information   |                  |                |                |
| to be         |                  |                |                |
| provided and  |                  |                |                |
| li            |                  |                |                |
| mitations):** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+
| **10.         |                  |                |                |
| ATTACHMENTS** |                  |                |                |
+---------------+------------------+----------------+----------------+
| Please        |                  |                |                |
| indicate      |                  |                |                |
| which         |                  |                |                |
| materials are |                  |                |                |
| being         |                  |                |                |
| submitted     |                  |                |                |
| with this     |                  |                |                |
| POA:          |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| A: Boring     |                  |                |                |
| logs and/or   |                  |                |                |
| other         |                  |                |                |
| subsurface    |                  |                |                |
| information** |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| B: Cross      |                  |                |                |
| sections from |                  |                |                |
| current and   |                  |                |                |
| previous      |                  |                |                |
| inspection    |                  |                |                |
| reports**     |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| C: Bridge     |                  |                |                |
| elevation     |                  |                |                |
| showing       |                  |                |                |
| existing      |                  |                |                |
| streambed,    |                  |                |                |
| foundation    |                  |                |                |
| depth(s) and  |                  |                |                |
| observed      |                  |                |                |
| and/or        |                  |                |                |
| calculated    |                  |                |                |
| scour         |                  |                |                |
| depths**      |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| D: Plan view  |                  |                |                |
| showing       |                  |                |                |
| location of   |                  |                |                |
| scour holes,  |                  |                |                |
| debris,       |                  |                |                |
| etc.**        |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| E: Map        |                  |                |                |
| showing       |                  |                |                |
| detour        |                  |                |                |
| route(s)**    |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| F: Supporting |                  |                |                |
| d             |                  |                |                |
| ocumentation, |                  |                |                |
| calculations, |                  |                |                |
| estimates and |                  |                |                |
| conceptual    |                  |                |                |
| designs for   |                  |                |                |
| scour         |                  |                |                |
| coun          |                  |                |                |
| termeasures.\ |                  |                |                |
| **            |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| G: Photos**   |                  |                |                |
|               |                  |                |                |
| **Attachment  |                  |                |                |
| H: Other      |                  |                |                |
| i             |                  |                |                |
| nformation:** |                  |                |                |
| [             |                  |                |                |
| ]{.underline} |                  |                |                |
+---------------+------------------+----------------+----------------+