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e. Does the project site contain, or is it substantially contiguous to, a building, archaeological site, or district 9 Yes 9 No
which is listed on the National or State Register of Historic Places, or that has been determined by the Commissioner of the NYS
Office of Parks, Recreation and Historic Preservation to be eligible for listing on the State Register of Historic Places?
If Yes:
i.Nature of historic/archaeological resource: 9 Archaeological Site 9 Historic Building or District
ii.Name: _________________________________________________________________________________________________
iii.Brief description of attributes on which listing is based:
_______________________________________________________________________________________________________
f. Is the project site, or any portion of it, located in or adjacent to an area designated as sensitive for 9 Yes 9 No
archaeological sites on the NY State Historic Preservation Office (SHPO) archaeological site inventory?
g. Have additional archaeological or historic site(s) or resources been identified on the project site?9 Yes 9 No
If Yes:
i. Describe possible resource(s): _______________________________________________________________________________
ii.Basis for identification: ___________________________________________________________________________________
h.9 Yes 9 No Is the project site within fives miles of any officially designated and publicly accessible federal, state, or local
scenic or aesthetic resource?
If Yes:
i.Identify resource: _________________________________________________________________________________________
ii.Nature of, or basis for, designation (e.g., established highway overlook, state or local park, state historic trail or scenic byway,
etc.): ___________________________________________________________________________________________________
iii.Distance between project and resource: _____________________ miles.
i. Is the project site located within a designated river corridor under the Wild, Scenic and Recreational Rivers 9 Yes 9 No
Program 6 NYCRR 666?
If Yes:
i.Identify the name of the river and its designation: ________________________________________________________________
ii.Is the activity consistent with development restrictions contained in 6NYCRR Part 666?9 Yes 9 No
F. Additional Information
Attach any additional information which may be needed to clarify your project.
If you have identified any adverse impacts which could be associated with your proposal, please describe those impacts plus any
measures which you propose to avoid or minimize them.
G. Verification
I certify that the information provided is true to the best of my knowledge.
Applicant/Sponsor Name ___________________________________ Date_______________________________________
Signature________________________________________________ Title_______________________________________
Chris Clark