0120-PM-PY0003 Rev. 5/2006
    COMMONWEALTH OF PENNSYLVANIA
    INSTRUCTIONS
    DEPARTMENT OF ENVIRONMENTAL PROTECTION
    INSTRUCTIONS FOR COMPLETING
    CULTURAL RESOURCE NOTICE
    - 1 -
    GENERAL INFORMATION
    This package is designed to assist the applicant in completing the
    necessary documentation regarding archaeological sites and historic
    structures encountered while undertaking permitting projects.
    This form is to be completed, signed, and dated by applicants for
    certain DEP permits or plan approvals. Please refer to the List of
    Exemptions for a list of applications which are exempt from this
    requirement. It is the responsibility of the applicant to complete this
    form and mail it to the PHMC at the following address:
    Pennsylvania Historical and Museum Commission
    Bureau of Historic Preservation
    400 North Street, Second Floor
    Harrisburg, PA 17120-0093
    Please be aware that PHMC will keep the Notice and submitted
    materials for its files. Therefore, keep a copy of the Notice and any
    materials submitted with it. Applicants should mail all Cultural
    Resource Notices “Certified Mail Return Receipt Requested” in order to
    prove submission and the date PHMC received the Notice.
    Attach a copy of your completed Cultural Resource Notice and the
    return receipt to your permit application.
    SECTION A. APPLICANT IDENTIFIER
    For purposes of identifying and tracking complete permit packages,
    enter the following requested information.
    APPLICANT NAME.
    Please insert applicant name using the same
    name as will be used with the Permit Application. Also, please insert
    applicant address and phone number. (Note: This would not
    be the
    consultant or engineering firm preparing the application.)
    PROJECT TITLE.
    Please enter the title of the project as will be used
    with the Permit Application.
    SECTION B. LOCATION OF PROJECT
    MUNICIPALITY.
    Indicate the municipality(ies) in which the site is
    located. If the site is located in more than two municipalities, attach a
    separate sheet of paper.
    COUNTY.
    Indicate the county(ies) in which the site is located. Write
    out the county name and also give the DEP county code. (County
    codes are provided on page 2 of these instructions.) If the site is
    located in more than two counties, attach a separate sheet of paper.
    SECTION C. PERMITS OR APPROVALS
    Give the name(s) of specific DEP permit or approval. Check the
    appropriate box for any anticipated federal permits that may be
    required.
    SECTION D. GOVERNMENT FUNDING
    SOURCES
    Indicate any authorized or anticipated governmental funding source
    and give the name of this funding source, i.e., PennVest or Rural Utility
    Services.
    SECTION E. RESPONSIBLE DEP REGIONAL,
    CENTRAL, DISTRICT MINING, OR OIL AND GAS
    MANAGEMENT OFFICE
    Check the appropriate box that identifies the DEP Regional, Central,
    District Mining, or Oil and Gas Management Office that is responsible
    for the review of this permit application. A list of DEP offices and
    counties supported is included at the end of these instructions.
    SECTION F. COUNTY CONSERVATION
    DISTRICT
    Some permit applications are reviewed by County Conservation
    Districts. If this is the case, give the name of the district office and the
    telephone number, if known.
    SECTION G. CONSULTANT IDENTIFIER
    For purposes of avoiding confusion should the consultant submit the
    determination notice to PHMC for the applicant, enter the following
    requested information: Consultant Engineer Name, Address and
    Telephone Number.
    SECTION H. PROJECT BOUNDARIES AND
    DESCRIPTION
    Assure that the following items are attached and submitted with the
    Notice form:
    • 7.5' USGS Map indicating boundaries of the proposed activity.
    Maps should include all relevant details. (Example: For a sewage
    facilities plan, the location of proposed sewerage facilities, including
    collection sewers, interceptor lines, pump stations and sewage
    treatment plants would be relevant information that PHMC would
    need.)
    • Narrative description of the proposed activity.
    • Photographs of any buildings over 50 years old. Indicate what is to
    be done to all buildings in the project area.
    • Indicate the total acres in the property under review. Of this
    acreage, indicate the total acres of earth disturbance for the
    proposed activity.
    • The return receipt of delivery of this Notice to the Pennsylvania
    Historical and Museum Commission.
    PHMC requests the following items:
    • Photographs of any buildings over 40 years old.
    • Site maps of the proposed activity, if available.
    SECTION I. SIGNATURE BLOCK
    A legally responsible agent of the applicant should complete and sign
    the notice. If this form is prepared by someone else, such as a
    consultant or contractor, that individual should complete and sign the
    notice.

    0120-PM-PY0003 Rev. 5/2006 INSTRUCTIONS FOR COMPLETING CULTURAL RESOURCE NOTICE, continued
    - 2 -
    SECTION B. LOCATION OF PROJECT
    County Codes:
    01 Adams
    24 Elk
    47
    Montour
    02 Allegheny
    25 Erie
    48
    Northampton
    03 Armstrong
    26 Fayette
    49
    Northumberland
    04 Beaver
    27 Forest
    50
    Perry
    05 Bedford
    28 Franklin
    51
    Philadelphia
    06 Berks
    29 Fulton
    52
    Pike
    07 Blair
    30 Greene
    53
    Potter
    08 Bradford
    31 Huntingdon
    54
    Schuylkill
    09 Bucks
    32 Indiana
    55
    Snyder
    10 Butler
    33 Jefferson
    56
    Somerset
    11 Cambria
    34 Juniata
    57
    Sullivan
    12 Cameron
    35 Lackawanna
    58
    Susquehanna
    13 Carbon
    36 Lancaster
    59
    Tioga
    14 Centre
    37 Lawrence
    60
    Union
    15 Chester
    38 Lebanon
    61
    Venango
    16 Clarion
    39 Lehigh
    62
    Warren
    17 Clearfield
    40 Luzerne
    63
    Washington
    18 Clinton
    41 Lycoming
    64
    Wayne
    19 Columbia
    42 McKean
    65
    Westmoreland
    20 Crawford
    43 Mercer
    66
    Wyoming
    21 Cumberland
    44 Mifflin
    67
    York
    22 Dauphin
    45 Monroe
    23 Delaware
    46 Montgomery
    99
    Out of State
    PA Dept. of Environmental Protection
    SE Regional Office
    2 East Main Street
    Norristown, PA 19401-4915
    Phone: (484) 250-5900
    Counties:
    Bucks, Chester, Delaware, Montgomery and Philadelphia
    PA Dept. of Environmental Protection
    NE Regional Office
    Two Public Square
    Wilkes-Barre, PA 18711-0790
    Phone: (570) 826-2511
    Counties:
    Carbon, Lackawanna, Lehigh, Luzerne, Monroe,
    Northampton, Pike, Schuylkill, Susquehanna, Wayne and Wyoming
    PA Dept. of Environmental Protection
    SC Regional Office
    909 Elmerton Avenue
    Harrisburg, PA 17110-8200
    Phone: (717) 705-4700
    Counties:
    Adams, Bedford, Berks, Blair, Cumberland, Dauphin,
    Franklin, Fulton, Huntingdon, Juniata, Lancaster, Lebanon, Mifflin,
    Perry and York
    PA Dept. of Environmental Protection
    NC Regional Office
    208 West 3rd Street, Suite 101
    Williamsport, PA 17701-6448
    Phone: (717) 570-3636
    Counties:
    Bradford, Cameron, Clearfield, Centre, Clinton, Columbia,
    Lycoming, Montour, Northumberland, Potter, Snyder, Sullivan, Tioga
    and Union
    PA Dept. of Environmental Protection
    SW Regional Office
    400 Waterfront Drive
    Pittsburgh, PA 15222-4745
    Phone: (412) 442-4000
    Counties:
    Allegheny, Armstrong, Beaver, Cambria, Fayette, Greene,
    Indiana, Somerset, Washington and Westmoreland
    PA Dept. of Environmental Protection
    NW Regional Office
    230 Chestnut Street
    Meadville, PA 16335-3481
    Phone: (814) 332-6945
    Counties:
    Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
    Lawrence, McKean, Mercer, Venango and Warren
    PA Dept. of Environmental Protection
    Central Office
    400 Market Street
    P.O. Box 8554
    Harrisburg, PA 17105-8554
    Phone: (717) 787-5027
    PA Dept. of Environmental Protection
    Oil and Gas Management
    Rachel Carson State Office Building
    5th Floor
    400 Market Street
    P.O. Box 8765
    Harrisburg, PA 17105-8765
    Phone: (717) 772-2199
    PA Dept. of Environmental Protection
    Oil and Gas Management
    Northwest Regional Office
    230 Chestnut Street
    Meadville, PA 16335-3481
    Phone: (814) 332-6860
    PA Dept. of Environmental Protection
    Oil and Gas Management
    Southwest Regional Office
    400 Waterfront Drive
    Pittsburgh, PA 15222-4745
    Phone: (412) 442-4000
    DEP REGIONAL AND CENTRAL OFFICES
    DEP OIL AND GAS OFFICES

    0120-PM-PY0003 Rev. 5/2006 INSTRUCTIONS FOR COMPLETING CULTURAL RESOURCE NOTICE, continued
    - 3 -
    PA Dept. of Environmental Protection
    Greensburg District Office
    Armbrust Professional Center
    8205 Route 819
    Greensburg, PA 15601
    Phone: (724) 925-5500
    Counties:
    Allegheny, Armstrong, Beaver, Fayette, Greene,
    Washington and Westmoreland
    PA Dept. of Environmental Protection
    Cambria District Office
    286 Industrial Park Road
    Ebensburg, PA 15931-4119
    Phone: (814) 472-1900
    Counties:
    Bedford, Blair, Cambria, Fulton, Huntingdon, Indiana and
    Somerset
    PA Dept. of Environmental Protection
    Pottsville District Office
    5 West Laurel Boulevard
    Pottsville, PA 17901-2454
    Phone: (570) 621-3118
    Counties:
    Adams, Berks, Bucks, Carbon, Chester, Columbia,
    Cumberland, Dauphin, Delaware, Franklin, Juniata, Lackawanna,
    Lancaster, Lebanon, Lehigh, Luzerne, Mifflin, Monroe, Montgomery,
    Montour, Northampton, Northumberland, Perry, Philadelphia, Pike,
    Schuylkill, Snyder, Susquehanna, Union, Wayne, Wyoming, and York
    DEP DISTRICT MINING OFFICES
    PA Dept. of Environmental Protection
    Moshannon District Office
    186 Enterprise Drive
    Philipsburg, PA 16866-1860
    Phone: (814) 342-8200
    Counties:
    Bradford, Cameron, Centre, Clearfield, Clinton, Lycoming,
    Potter, Sullivan and Tioga
    PA Dept. of Environmental Protection
    California District Office
    25 Technology Drive
    California Technology Park
    Coal Center, PA 15423-1051
    Phone: (724) 769-1100
    Serving:
    All of Western Pennsylvania
    PA Dept. of Environmental Protection
    Knox District Office
    White Memorial Building
    P.O. Box 669
    Best Avenue
    Knox, PA 16232-0669
    Phone: (814) 797-1191
    Counties:
    Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson,
    Lawrence, McKean, Mercer, Venango and Warren

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