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PROJECT REVIEW FORM Request for Comments from the Maryland Historical Trust/ MDSHPO on State and Federal Undertakings Section A General Project Information Date Received MHT USE ONLY Submit hard copy of form and all attachments to Beth Cole MHT 100 Community Place Crownsville MD 21032 Project Name Log Number Print Form County This is a new submittal OR This is additional information related Project Log Number Section B Primary Contact Information Company/Agency Contact Name Mailing Address City State MD Email Phone Number Zip Ext. Section C Description of Undertaking Location - Attach a map preferably a section of a USGS quad showing the location and boundaries of the project City/Vicinity Address List all federal and state agencies / programs funding permits licenses involved in this project e*g* Bond Bill Loan of 2009 Chapter Transportation Enhancement Grant HUD/CDBG MDE/COE permit etc*. Agency Type Agency/Program/Permit Name Proposed Work - Attach project description scope of work site plans / drawings This project includes check all applicable Demolition New Construction Project/Permit/Tracking Number if applicable Remodeling/Rehabilitation State or Federal Rehabilitation Tax Credits Properties subject to an easement held by MHT MET or another entity Section D Identification of Historic Properties Properties designated as historic by a local government listed in the National Register or included in Maryland Inventory of Historic Properties Property/District Name The subject property has has not been the subject of previous archeological architectural or historical investigations. Please describe Attachments Map Project Description/Scope of Work Site Plans/Drawings Photographs - Attach prints or digital photographs showing the project site including images of all buildings and structures preferably keyed to a site plan Conditions - Attach a brief description of past and present conditions of the project area wooded mined developed agricultural uses etc including construction dates of buildings if known* MHT Determination MHT Reviewer Date There are NO HISTORIC PROPERTIES in the area of potential effect The project will have NO ADVERSE EFFECT WITH CONDITIONS MHT REQUESTS ADDITIONAL INFORMATION. Section C Description of Undertaking Location - Attach a map preferably a section of a USGS quad showing the location and boundaries of the project City/Vicinity Address List all federal and state agencies / programs funding permits licenses involved in this project e*g* Bond Bill Loan of 2009 Chapter Transportation Enhancement Grant HUD/CDBG MDE/COE permit etc*. Agency Type Agency/Program/Permit Name Proposed Work - Attach project description scope of work site plans / drawings This project includes check all applicable Demolition New Construction Project/Permit/Tracking Number if applicable Remodeling/Rehabilitation State or Federal Rehabilitation Tax Credits Properties subject to an easement held by MHT MET or another entity Section D Identification of Historic Properties Properties designated as historic by a local government listed in the National Register or included in Maryland Inventory of Historic Properties Property/District Name The subject property has has not been the subject of previous archeological architectural or historical investigations. .

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