0120-PM-PY0003 Rev. 5/2006
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
CULTURAL RESOURCE NOTICE
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with no action, or will be considered withdrawn and the application file closed.
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
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 submittal.
d) Submitted application to County Conservation District Office on
with copy of
Return Receipt from PHMC as proof of submittal.
Attachments requested, where appropriate
a) Section H - Photographs of any buildings over 40 years old.
b) Section H - Site maps of the proposed activity, if available.