0120-PM-PY0003 Rev. 5/2006

    Checklist
    COMMONWEALTH OF PENNSYLVANIA

    DEPARTMENT OF ENVIRONMENTAL PROTECTION

    CULTURAL RESOURCE NOTICE

    APPLICANT’S ü CHECKLIST
    Please check the following list to make sure that you have included all the required information. Place a checkmark in the column provided for all items completed and/or provided.
    Failure to provide all of the requested information will delay the processing of the application and may result in the application being placed on hold with no action, or will be considered withdrawn and the application file closed.
     
    Requirement
    Check ü

    If Included

    1. Attachments, where appropriate  
      a)  Section B - Additional municipality information.  
      b)  Section B - Additional county information.  
      c)  Section H - 7.5' USGS Map (with defined boundaries of proposed activity).  
      d)  Section H - Narrative description of proposed activity.  
      e)  Section H - Photographs of any buildings over 50 years old. Indicate what is to be done to all buildings in the project area.  
      f)  Section H - Total acres in property under review. Of this acreage, total acres of earth disturbance for the proposed activity.  
      g)  Return receipt of delivery of Cultural Resource Notice to the Pennsylvania Historical and Museum Commission.  
    2. Mailings  
      a)  Notice mailed to PHMC on        .  
      b)  Received return receipt from PHMC on        .  
      c)  Submitted application to DEP Regional, Central, District Mining or Oil and Gas Mgmt. Office on

               with copy of return receipt from PHMC as proof of submitta l.

     or  

     
     
    d)  Submitted application to County Conservation District Office on          with copy of Return Receipt from PHMC as proof of submittal.
     
     
    Requests
    Check ü

    If Included

    3. Attachments requested, where appropriate  
      a)  Section H - Ph otographs of any buildings over 40 years old.  
      b)  Section H - Site maps of the proposed activity, if available.    

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