Date: _______________________

Name of Applicant: __________________________________

Utility ID: ________________________________________

Location (Address, Provide Map): __________________________________________________

Route Description:_______________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Area Description: Photo Documentation: _ Yes _ No

_ Urban

_ Suburban

_ Rural

Substrate:

_ Asphalt/Concrete

_ Soil

_ Other: ____________________________________________________________________

Archaeological Resources:

_ Yes _ No CHRIS Records Search

_ Yes _ No Request NAHC contact list and query Sacred Lands File

_ Yes _ No Contact Parties on the NAHC list by letter and phone (identify concerns and sites)

_ Yes _ No Site visit/survey (identify architectural, historic, and prehistoric resources)

Notes and Recommendations: ______________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________