1000-FM-OA0064B 10/16/06

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

APPLICATION FOR QUICK RESPONSE REPAIR

SECTION I
To be completed by task applicant:
Date: / Name of Applicant Organization:
Contact Person: / Address:

Telephone: / Fax: / E-Mail:
Original Project Title
Contract/Agreement Number(s) (if any)
Project Location (township, county, watershed) Attach copy of topographic map showing site location
Funding source(s)
Year(s) funded
Description of original project:


Describe nature of problem and proposed repair:

Justification for need for Quick Response funding (failure to act quickly will likely result in serious environmental consequences or will contribute to further damage of a project):

Does an operations, maintenance and repair plan exist? Yes No
Proposed Contractor Name: / Contractor Address:

Contractor Telephone: / Contractor Fax: / Contractor E-Mail:
Contractor FEIN #/SAP Vendor # : / Contractor’s Cost Estimate (attach copy):
$
Landowner permission required. Attach copy of signed landowner agreement
Are permits required for this repair? Yes No
If yes, have they been obtained? Yes No / Matching Funds
$
Contact person signature / Date
FORWARD THIS DOCUMENT AND ATTACHMENTS TO APPROPRIATE DEP REGIONAL WATERSHED MANAGER OR DISTRICT MINING WATERSHED MANAGER. (SEE ATTACHED)
SECTION II
To be completed by DEP Regional Watershed Manager or District Mining Watershed Manager:
Is project eligible for GGII funding? (applicant eligibility should not be evaluated) Yes No
Do you agree this project is in need of quick response funds? (failure to act quickly will likely result in serious environmental consequences or will contribute to further damage of a project) Yes No
CRP/e-FACTS check performed and acceptable for proposed contractor? Yes No
Estimated costs appear reasonable? Yes No
If permits are required, have they been obtained? Yes No
Recommended for funding as submitted? (If yes on all of the above) Yes No Amount $
(If you feel this project is fundable with modifications, check no and advise applicant to submit a new application.)
Comments:

DEP Regional Watershed Manager/District Mining Watershed Manager:
Name (print): / Telephone: / E-mail:
Signature: / Date:
FORWARD THIS DOCUMENT AND ATTACHMENTS TO DEP REGIONAL WATERSHED PROGRAM MANAGER OR DISTRICT MINING MANAGER FOR AUTHORIZATION

SECTION III

To be completed by DEP Regional Watershed Program Manager or District Mining Manager:
Do you authorize this project? Yes No
If no, provide comments:

DEP Regional Watershed Program Manager/District Mining Manager:
Signature: / Date:
FORWARD THIS DOCUMENT AND ATTACHMENTS TO WPCAMR AT THE FOLLOWING ADDRESS:
WPCAMR
Attn: Andy McAllister
WPCAMR
226 Donohoe Road Suite 110
Greensburg, PA 15601

SECTION IV

To be completed by WPCAMR:
Funding is dependent upon authorization from DEP Regional Watershed Program Manager/DistrictMining Manager and availability of funds. Are both of these funding criteria met? Yes No
Amount of Funding Authorized:
$ / Application Number:
Expiration date of task contract (90 days from last signature date)
WPCAMR Signature: / Date:
IF FUNDED, RETAIN THIS DOCUMENT AND ATTACHMENTS AND SEND AUTHORIZATION FOR QUICK REPAIR AND REIMBURSEMENT FORM TO APPLICANT.
IF NOT FUNDED, NOTIFY APPLICANT IN WRITING WITH A CC TO THE DEP REGIONAL WATERSHED MANAGER OR DISTRICT MINING WATERSHED MANAGER.

- 1 -

1000-FM-OA0064B 10/16/06

To contact a DEP Mineral Resources Watershed Manager, refer to the following directory:

- 1 -

1000-FM-OA0064B 10/16/06

District Mining Offices

Pottsville District Mining Office

(Watershed Manager, Dan Koury)

5 W. Laurel Blvd.

Pottsville, PA 17901-2454

Telephone: 570-621-3118

Counties Served: Adams, Berks, Bucks, Carbon, Chester, Columbia, Cumberland, Dauphin, Delaware, Franklin, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Mifflin, Monroe, Montgomery, Montour, Northampton, Northumberland, Perry, Pike, Philadelphia, Schuylkill, Snyder, Susquehanna, Union, Wayne, Wyoming and York

Moshannon District Office

(Contact,Mario Carrello)

186 Enterprise Drive

Phillipsburg, PA 16866

Telephone: 814-342-8200

Counties Served: Bradford, Cameron, Centre, Clearfield, Clinton, Lycoming, Potter, Sullivan and Tioga

Knox District Mining Office

(Watershed Manager, Sherry Carlin)

WhiteMemorialBuilding, P.O. Box 669

Knox, PA 16232-0669

Telephone: 814-797-1191

Counties Served: Butler, Clarion, Crawford, Elk, Erie, Forest, Jefferson, Lawrence, McKean, Mercer, Venango and Warren

Cambria District Mining Office

(Contact, Malcolm Crittenden)

286 Industrial Park Road

Ebensburg, PA 15931-4119

Telephone: 814-472-1900

Counties Served: Bedford, Blair, Cambria, Fulton, Huntingdon, Indiana and Somerset

Greensburg District Mining Office

(Watershed Manager, Ron Horansky)

ArmbrustProfessionalCenter

8205 Route 819

Greensburg, PA 15601-8739

Telephone: 724-925-5500

Counties Served: Allegheny, Armstrong, Beaver, Fayette, Greene, Washington and Westmoreland

Bureau of Abandoned Mine Reclamation

Wilkes-Barre District Office

(Contact, Mike Korb)

2 Public Square, 5th Floor

Wilkes-Barre, PA 18711-0790

570-826-5486

Counties Served: All anthracite counties

Cambria District Office

(Contact, Pam Milavec)

286 Industrial Park Road

Ebensburg, PA 15931-4119

814-472-1800

Counties Served: All bituminous counties

- 1 -

1000-FM-OA0064B 10/16/06

To contact a DEP Regional Watershed Manager, refer to the following directory:

PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION

Northwest Regional Office
230 Chestnut St.
Meadville, PA 16335-3481
814-332-6848
Watershed Manager
Tim Bruno / Northcentral Regional Office
208 W. Third St., Suite 101
Williamsport, PA 17701-6448
570-327-3423
Watershed Managers
Jason Fellon / Northeast Regional Office
2 Public Square
Wilkes-Barre, PA 18711-0790
570-826-2511
Watershed Managers
Ron Yablonsky
Southwest Regional Office
400 Waterfront Drive
Pittsburgh, PA 15222-4745
412-442-4000
Watershed Managers
Jeff Fliss / Southcentral Regional Office
909 Elmerton Avenue
Harrisburg, PA 17110-8200
717-705-4700
Watershed Managers
Jineen Boyle / Southeast Regional Office
Two East Main Street
Norristown, PA 19401
484-250-5900
Watershed Managers
Dave Burke

- 1 -

1000-FM-OA0064B 10/16/06

AUTHORIZATION FOR QUICK RESPONSE REPAIR

AND REIMBURSEMENT FORM

SECTION I
To be completed by WPCAMR:
Application Number: / Name of Applicant Organization:
Contact Person: / Address:

Telephone: / Fax: / E-Mail:
You are authorized to proceed with quick response repair as submitted in your application dated
in the amount of $.
Signature: / Date:

FORWARD THIS DOCUMENT TO THE APPLICANT

SECTION II
Instructions to Applicant:
You must retain this form in order to receive reimbursement.
Prior to commencing construction, notify your DEP Regional Watershed Manager or District Mining Watershed Manager.
Upon completion of construction (or phase of construction), contact your DEP Regional Watershed Manager or District Mining Watershed Manager to arrange a site inspection. This is a mandatory requirement for reimbursement.
This form and contractor invoices must be provided to the DEP Regional Watershed Manager or District Mining Watershed Manager at site inspection.
Reimbursement will only occur if repair is satisfactorily completed in accordance with the Application as determined by the DEP Regional Watershed Manager or District Mining Watershed Manager at site inspection.
I hereby assign payment rights to:
Amount of Reimbursement Requested: $Partial Reimbursement Request
Date Work Completed : Final Reimbursement Request
Signature: Date:
SECTION III
To be completed by DEP Regional Watershed Manager or District Mining Watershed Manager:
Site visit conducted? Yes No
Authorize payment? Yes No
If no, please provide comments and notify Pam Milavec at 814-472-1832.
DEP Regional Watershed Manager/District Mining Watershed Manager:
Name (print): / Telephone: / E-mail:
Signature: / Date:
FORWARD APPLICATION FOR QUICK RESPONSE AND REIMBURSEMENT FORM, ALONG WITH CONTRACTOR INVOICE, TO:
WPCAMR
Attn: Andy McAllister
WPCAMR
226 Donohoe Road Suite 110
Greensburg, PA 15601
SECTION IV
Instructions for WPCAMR:
If payment is authorized by DEP Regional Watershed Manager or District Mining Watershed Manager, proceed with payment to applicant and submit necessary documentation to Pam Milavec for reimbursement.
If payment is not authorized, provide all relevant documentation to:
Pam Milavec
Bureau of Abandoned Mine Reclamation
Cambria District Office
286 Industrial Park Road
Ebensburg, PA 15931-4119

- 1 -