|0120-PM-PY0003 Rev. 5/2006||
COMMONWEALTH OF PENNSYLVANIA
DEP USE ONLY
DEPARTMENT OF ENVIRONMENTAL PROTECTION
CULTURAL RESOURCE NOTICE
Read the instructions before completing this form.
|SECTION A. APPLICANT IDENTIFIER|
|SECTION B. LOCATION OF PROJECT|
|Municipality||County Name||DEP County Code|
|SECTION C. PERMITS OR APPROVALS|
|Name of Specific DEP Permit or Approval Requested:|
|Anticipated federal permits:|
|Surface Mining||404 Water Quality Permit|
|Army Corps of Engineers||Federal Energy Regulatory Commission|
|401 Water Quality Certification||Other:|
|SECTION D. GOVERNMENT FUNDING SOURCES|
|SECTION E. RESPONSIBLE DEP REGIONAL, CENTRAL, DISTRICT MINING or OIL & GAS MGMT OFFICE|
|DEP Regional Office Responsible for Review of Permit Application||Central Office (Harrisburg)|
|Southeast Regional Office (Norristown)||Northeast Regional Office (Wilkes-Barre)|
|Southcentral Regional Office (Harrisburg)||Northcentral Regional Office (Williamsport)|
|Southwest Regional Office (Pittsburgh)||Northwest Regional Office (Meadville)|
|District Mining Office:||Oil & Gas Office:|
|SECTION F. RESPONSIBLE COUNTY CONSERVATION DISTRICT, if applicable.|
|County Conservation District||Telephone Number, if k nown|
|SECTION G. CONSULTANT|
|Consultant, if applicable|
|SECTION H. PROJECT BOUNDARIES AND DESCRIPTION|
Indicate the total acres in the property under review. Of this acreage, indicate the total acres of earth disturbance for the proposed activity.
Attach a 7.5' U.S.G.S. Map indicating the defined boundary of the proposed activity.
Attach photographs of any building over 50 years old. Indicate what is to be done to all buildings in the project area.
Attach a narrative description of the proposed activity.
Attach the return receipt of delivery of this notice to the Pennsylvania Historical and Museum Commission.
Attach photographs of any building over 40 years old.
Attach site map, if available.
|SECTION I. SIGNATURE BLOCK|
|Date of Submission of Notice to PHMC|
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