3150-PM-BWEW0510 10/2012
    COMMONWEALTH OF PENNSYLVANIA
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    BUREAU OF WATERWAYS ENGINEERING AND WETLANDS
    EXHIBIT D
    NOTIFICATION TO USE
    BDWW-GP-10
    ABANDONED MINE RECLAMATION
    1.
    I/We
    ,
    (owner name(s))
    hereby notify the Department of Environmental Protection of our intent to
    (description of activity)
    at a point
    (describe location)
    in
    ,
    (municipality)
    (county)
    2.
    I/We have attached a LOCATION MAP of the abandoned mine reclamation indicating the site and a
    copy of the PNDI form with initialed Search Receipt.
    3.
    I/We have enclosed duplicate copies of EXHIBIT D, the LOCATION MAP, and PNDI form with initialed
    Search Receipt.
    4.
    I/We certify that copies of this notification were sent this day
    (date)
    to
    , and
    .
    (municipality)
    (County - Commissioner’s Office)
    5.
    I/We certify that an EROSION AND SEDIMENT CONTROL PLAN for this project will be
    submitted for review by the contractor to the
    County Conservation
    District prior to construction activities. No earthmoving activities will commence without plan approval.
    Signed by:
    (print name)
    (owner address)
    (owner signature)
    (city/state/zip code)
    (title, if applicable)
    (owner telephone number)
    6.
    All temporary road crossings of the regulated waters of the Commonwealth in areas unaffected by
    mining activities shall be constructed in accordance with the design standards and conditions of General
    Permit BDWM-GP-8.
    Signed:
    ACKNOWLEDGED:
    DATE
    GP
    FOR DEPT. USE ONLY

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