0120-PM-PY0003 Rev. 5/2006
    COMMONWEALTH OF PENNSYLVANIA
    DEP USE ONLY
    NOTICE
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    Date Received
    CULTURAL RESOURCE NOTICE
    Read the instructions before completing this form.
    SECTION A. APPLICANT IDENTIFIER
    Applicant Name
    Street Address
    City
    State
    Zip
    Telephone Number
    Project Title
    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
    State:
    (Name)
    Local:
    (Name)
    Federal:
    (Name)
    Other:
    (Name)
    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 known
    SECTION G. CONSULTANT
    Consultant, if applicable
    Street Address
    City
    State
    Zip
    Telephone Number

    0120-PM-PY0003 Rev. 5/2006
    - 2 -
    SECTION H. PROJECT BOUNDARIES AND DESCRIPTION
    REQUIRED
    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.
    REQUESTED
    Attach photographs of any building over 40 years old.
    Attach site map, if available.
    SECTION I. SIGNATURE BLOCK
    Applicant’s Signature
    Date of Submission of Notice to PHMC

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