FCC Form 621 FCC Wireless Telecommunications Bureau Collocation (“CO”

FCC Form 621 FEDERAL COMMUNICATIONS COMMISSION Approved by OMB

3060 -1039

Information and Instructions Est. Avg. Burden

Per Response:

5 to 20 Hrs

FCC Wireless Telecommunications Bureau

Collocation (“CO”) Submission Packet

NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT OF 1974 AND

THE PAPERWORK REDUCTION ACT OF 1995

We have estimated that each response to this collection of information will take on average 5- 20 hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington, DC 20554, Paperwork Reduction Project (3060-1039). We will also accept your comments via the Internet if you send them to [email protected]. Please do not send completed application forms to this address.

You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection unless it displays a currently valid OMB control number with this notice. This collection has been assigned OMB control number 3060-1039.

The FCC is authorized under the Communications Act of 1934, as amended, to collect the personal information we request in this form. We will use the information you provide to determine whether approving this application is in the public interest. If we believe there may be a violation or potential violation of a statute, FCC regulation, rule or order, your application may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing or implementing the statute, rule, regulation or order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government, is a party to a proceeding before the body or has an interest in the proceeding.

All parties and entities doing business with the Commission must obtain a unique identifying number called the FCC Registration Number (FRN) and supply it when doing business with the Commission. Failure to provide the FRN may delay the processing of the application. This requirement is to facilitate compliance with the Debt Collection Improvement Act of 1996 (DCIA). The FRN can be obtained electronically from the FCC’s website at http://www.fcc.gov or by manually submitting FCC Form 160. FCC Form 160 is available from the FCC’s web site at http://www.fcc.gov/formpage.html, by calling the FCC’s Forms Distribution Center at (800) 418-FORM (3676), or from the FCC’s Fax Information System by dialing (202) 418-0177.

This notice is required by the Privacy Act of 1974, Public Law 93-579, December 31, 1974, 5 U.S.C. Section 552a (e)(3), and the Paperwork Reduction Act of 1995, Public Law 104-13, October 1, 1995, 44 U.S.C. 3507.

General Instructions

Purpose of Form

FCC Form 621 is the CO Submission Packet is to be completed by or on behalf of Applicants who wish to collocate an antenna or antennas on an existing communications tower or non-tower structure by or for the use of licensees of the Federal Communications Commission (“FCC”)¹. The Packet (including Form CO and attachments) is to be submitted to the State Historic Preservation Office (“SHPO”) or to the Tribal Historic Preservation Office (“THPO”), as appropriate, before any construction or other installation activities on the site begin. Failure to provide the Submission Packet and complete the review process under Section 106 of the National Historic Preservation Act (“NHPA”)² prior to beginning construction or other installation activities may violate Section 110(k) of the NHPA and the Commission’s rules. The instructions below should be read in conjunction with, and not as a substitute for, the “Nationwide Programmatic Agreement for Review of Effects on Historic Properties for Certain Undertakings Approved by the Federal Communications Commission,” dated September 2004, (“Nationwide Agreement”), the “Nationwide Programmatic Agreement for the Collocation of Wireless Antennas” (“Collocation Agreement”)³, and the relevant rules of the FCC (47 C.F.R. §§ 1.1301-1.1319) and the Advisory Council on Historic Preservation (“ACHP”) (36 C.F.R. Part 800)⁴

Exclusions and Scope of Use

The CO Submission Packet should be submitted only for those collocations that are subject to Section 106 review. The CO Submission Packet should not be submitted for collocations that have been excluded from Section 106 Review by the Collocation Agreement or the Nationwide Programmatic Agreement. Where a collocation is to be completed but no submission will be made to a SHPO or THPO due to the applicability of one or more exclusions, the Applicant should retain in its files documentation of the basis for each exclusion should a question arise as to the Applicant’s compliance with Section 106. The CO Submission Packet is to be used only for the collocation of an antenna or antennas on an existing communications tower or a non-tower structure. New tower constructions that are subject to Section 106 review should be submitted using the New Tower (“NT”) Submission Packet (FCC Form 620).

Electronic Filers

Information about online filing of Form 621 is available from the Wireless Telecommunications Bureau website at http://wireless.fcc.gov/outreach/index.htm?job=tower_notification.

Applicants filing electronically should follow procedures contained in online help files. For technical assistance with filing electronically, contact the FCC at (877) 480-3201.

In instances where the Applicant files electronically and needs to include an exhibit(s) with the application and cannot transmit that exhibit(s) to the FCC electronically, the Applicant may mail exhibits to the following address:

Federal Communications Commission

Application Exhibit

1270 Fairfield Road

Gettysburg, PA 17325-7245

Hand-deliveries and messenger-deliveries should be delivered to Federal Communications Commission, 1280 Fairfield Road, Gettysburg, PA 17325.

Each exhibit should be clearly labeled with the Applicant’s name, the 10-digit file number assigned to the application at the time of submission, and the type of exhibit (e.g., waiver request).

Filing Locations

Paper applications should be submitted to the State Historic Preservation Office (“SHPO”) or to the Tribal Historic Preservation Office (“THPO”), as appropriate, before any construction or other installation activities on the site begin. Failure to provide the Submission Packet and complete the review process under Section 106 of the National Historic Preservation Act (“NHPA”) prior to beginning construction may violate Section 110(k) of the NHPA and the Commission’s rules.

Exhibits

Each document required to be filed as an exhibit should be current as of the date of filing. Each page of every exhibit must be identified with the number or letter of the exhibit, the number of the page of the exhibit, and the total number of pages of the exhibit. If material is to be incorporated by reference, see the instruction on incorporation by reference.

Note: Some Commission rules require Applicants to attach one or more exhibits to an application in addition to the information requested in the application form.

Incorporation by Reference

You may incorporate by reference documents, exhibits, or other lengthy showings already on file only if the information previously filed is more than one 8 1/2” by 11” page in length, all information therein is current and accurate in all significant respects, and the reference states specifically where the previously filed information can be found including exhibit and page references. Items that call for numbers or that can be answered ‘Y’ or ‘N’ or with other short answers must be answered directly without reference to a previous filing.

Assistance with Completing this Form

For assistance with this form, you may visit the FCC’s webpage at http://esupport.fcc.gov or call (877) 480-3201 (TTY (717) 338-2824). To provide quality service and ensure security, all telephone calls are recorded.

Instructions for FCC Form 621

General Information

Item 1 Indicate the purpose for which the application is being filed by inserting the appropriate two-letter abbreviation from the following list. Only one purpose may be specified.

Item 2 If the application is a request for an Update or Withdrawal of a previously-filed currently pending application, provide the file number of the original application. This information can be obtained by contacting the FCC (877) 480‑3201 (TTY 717-338-2824).

Applicant/Contact Information

Applicant/Contact Information

Item 3 Enter the ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from , by calling the FCC's Forms Distribution Center at (800) 418‑3676, or from the FCC’s Fax Information System by dialing (202) 418-0177.

Items 4-17 Enter the name of applicant in Item 4. Enter the individual to contact in Items 5 through 8 as well as the title in Item 9. You may enter a post office box number in Item 10 or a street address in Item 11, or enter information for both items. Enter the city, state, and zip code in Items 12, 13, and 14. Refer to Appendix I, for a list of valid state, jurisdiction, and area abbreviations. Enter a telephone number, including area code, in Item 15. Enter the fax number (including area code) and e-mail address, if desired and available, in items 16 and 17.

Consultant Information

Consultant/Principal Investigator/Principal Investigator Contact Information

Item 18 Enter the ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from , by calling the FCC’s Forms Distribution Center at (800) 418‑3676, or from the FCC’s Fax Information System by dialing (202) 418-0177.

Items 19-32 Enter the name of consultant in Item 19. Enter the Principal Investigator in Items 20 through 23 as well as the title in Item 24. You may enter a post office box number in Item 25 or a street address in Item 26, or enter information for both items. Enter the city, state, and zip code in Items 27, 28, and 29. Refer to Appendix I, for a list of valid state, jurisdiction, and area abbreviations. Enter a telephone number, including area code, in Item 30. Enter the fax number (including area code) and e-mail address, if desired and available, in items 31 and 32.

Consultant Information Attachments

You are required to provide a current copy of the resume or curriculum vitae for the Principal Investigator and any researcher or other person who contributed to, reviewed, or provided significant input into the research, analysis, writing or conclusions presented in this filing.

Professional Qualification

Items 33 & 34 Check Yes or No in Item 33 if the Principal Investigator satisfies the Secretary of the Interior’s Professional Qualification Standards and select the area(s) of professional qualification in Item 34.

NOTE: The Professional Qualification Standards are available on the cultural resources webpage of the National Park Service, Department of the Interior: <http://www.cr.nps.gov/local-law/arch_stnds_9.htm>. The Nationwide Programmatic Agreement requires use of Secretary-qualified professionals for identification and evaluation of historic properties within the APE for direct effects, and for assessment of effects. The Nationwide Programmatic Agreement encourages, but does not require, use of Secretary-qualified professionals to identify historic properties within the APE for indirect effects. See Nationwide Programmatic Agreement, §§ VI.D.1.d, VI.D.1.e, VI.D.2.b, VI.E.5.

Additional Staff

Items 35 through 41 Check Yes or No in Item 35 if there are other staff involved who meet the Professional Qualification Standards of the Secretary Interior. If “Yes” is checked, enter the name of the additional staff and select the appropriate area(s) of professional qualification. Items 37, 39 & 40 are optional. This section may be copied to include other additional staff.

NOTE: The Professional Qualification Standards are available on the cultural resources webpage of the National Park Service, Department of the Interior: <http://www.cr.nps.gov/local-law/arch_stnds_9.htm>. The Nationwide Programmatic Agreement requires use of Secretary-qualified professionals for identification and evaluation of historic properties within the APE for direct effects, and for assessment of effects. The Nationwide Programmatic Agreement encourages, but does not require, use of Secretary-qualified professionals to identify historic properties within the APE for indirect effects. See Nationwide Programmatic Agreement, §§ VI.D.1.d, VI.D.1.e, VI.D.2.b, VI.E.5.

Site Information

TCNS/Site Information

Items 1 through 9 Enter the TCNS notification number in Item (optional). Indicate whether or not this is a Positive Train Control (PTC) Filing Subject to Expedited Treatment Under Program Comment by entering a ‘Y’ or ‘N’ in Item 2. Enter the site name, address, detailed description of project, nearest city, state, zip code and county/borough/parish in Items 3 through 9 respectively. The Detailed Description of Project, Item 5 should include the number of wayside poles when submitting a PTC batch filing. Item 9 must be completed with the County/Borough/Parish or equivalent entity in which the tower is located unless any of the following pertain to the Fixed Location:

a) The City entered in Item 6 is an Independent City that is not affiliated with a County/Borough/Parish (e.g.., Baltimore, MD)

b) The State code entered in Item 7 does not have Counties/Boroughs/Parishes, enter the equivalent entity (e.g.., Puerto Rico, Virgin Islands)

c) The State code entered in Item 7 is GM, Gulf of Mexico

NOTE: If the nearest City, County/Borough/Parish or equivalent entity and State are located in a bordering County/Borough/Parish or equivalent entity and/or State, enter a complete description of the location in Item 4 as shown in the example. Complete Item 6 if a City, Town or Village within the tower’s County/Borough/Parish or equivalent entity is nearby, and complete Items 7, 8 and 9 with the State, Zip Code and County/Borough/Parish or equivalent entity in which the coordinates are actually located.

Example: 4) (Site Address) Summit Mtn near Palo Verde, Imperial County, CA

6) (City) Palo Verde

7) (State) AZ

9) (County/Borough/Parish) La Paz

Item 10 Enter the nearest crossroads to the tower site.

Item 11 Enter the latitude using the format DD‑MM‑SS.S, where the degrees (DD) term can have a value in the range of 0 to 72, minutes (MM) can range from 0 to 59, and seconds (SS.S) can range from 0 to 59.9. The seconds should be rounded to the nearest tenth of a second (in which case, use the format DD-MM-SS.S). Specify the direction as either N for North or S for South.

Item 12 Enter the longitude using the format DDD‑MM‑SS, where the degrees (DDD) term can have a value in the range of 64 to 180, minutes (MM) can range from 0 to 59, and seconds (SS.S) can range from 0 to 59.9. The seconds should be rounded to the nearest tenth of a second (in which case, use the format DDD-MM-SS.S). Specify the direction as either E for East or W for West.

NOTE: All coordinates must be referenced to the North American Datum of 1983 (NAD83). This information can be determined in many ways, including using a GPS receiver, or a 7.5-minute topographical quadrangle map of the area, or you may consult the city or county/borough/parish surveyor in your area. Topographical maps may be purchased from the U.S. Geological Survey, Washington, DC 20242 or from its office in Denver, Colorado 80225.

Site Information Attachments

You are required to provide photographs and maps as part of this filing. Additional site information can be provided in an optional attachment.

Photograph Requirements:

Except in cases where no Historic Properties were identified within the Areas of Potential Effects, submit photographs as described below. Photographs should be in color, marked so as to identify the project, keyed to the relevant map or text, and dated; the focal length of the lens and the height of the camera should be noted. The source of any photograph included but not taken by the Applicant or its consultant (including copies of historic images) should be identified on the photograph.

1. Photographs taken from the collocation site should show views from the proposed location in all directions. The direction (e.g., north, south, etc.) should be indicated on each photograph, and, as a group, the photographs should present a complete (360 degree) view of the area around the communications tower or non-tower structure.

2. Photographs of all listed and eligible properties within the Areas of Potential Effects.

3. If any listed or eligible properties are visible from the proposed collocation site, photographs looking at the site from each historic property. The approximate distance in feet (meters) between the site and the historic property should be included. If any listed or eligible properties are within the APE, photos looking at each historic property should be included.

Include aerial photos of the APE for visual effects, if available. There are a variety of publicly available websites that provide aerial photographs.

Map Requirements:

Include one or more 7.5-minute quad USGS topographical maps that:

1. Identify the Areas of Potential Effects for both Direct and Visual Effects. If a map is copied from the original, include a key with name of quad and date.

2. Show the location of the proposed collocation site and any new access roads or other easements including excavations.

3. Show the locations of each property listed.

4. Include keys for any symbols, colors, or other identifiers.

e. Submit color maps whenever possible.

Additional Site Information Recommendations:

Describe any additional structures, access roads, utility lines, fences, easements, or other construction planned for the site in conjunction with the proposed collocation and related facilities. Use this attachment to provide additional details needed to provide a full and accurate description of any structural alterations, additions, or other construction activities that will take place to complete the collocation.

Collocation Information

Item 13 Select the appropriate structure that the antenna will be collocated. If checking Communications Tower, select one of the options provided. If checking the Non-tower Structure, provide a description of the structure.

Item 14 Enter the tower height above ground (including top-mounted attachments such as lightning rods). Indicate whether you provided the height in feet or meters.

Item 15 Enter the description of antennas to be collocated (e.g. number, type, shape, dimensions, and color).

Item 16 Check Yes or No if the antennas will be placed at multiple levels on the structure. If “Yes”, describe the placement. If “No”, specify the height above ground and check either feet or meters.

Item 17 Enter the year of structure completion (YYYY). Check block if your year provided is approximate.

Item 18 Check Yes or No if the communications tower or non-tower structure has been the subject of SHPO/THPO review pursuant to Section 106 of the National Historic Preservation Act. If “Yes”, provide the company that made the submission, the date submitted (MM/DD/YYYY) and the SHPO/THPO reference number.

Item 19 Check Yes or No if the communications tower or non-tower structure is eligible for listing on the National Register.

Collocation Status

Current Collocation Status

Item 20 Select the appropriate category of the status of the project. When selecting “Construction and/or installation has commenced, but is not completed”, enter the date the construction and/or installation commenced. When selecting “Construction and/or installation has been completed”, enter the date the construction and/or installation commenced and the date the construction and/or installation was completed.

NOTE: Failure to submit this form and complete the review process under Section 106 of the NHPA prior to beginning construction or other installation activities may violate Section 110(k) of the NHPA and the Commission’s rules. See Section X of the Nationwide Programmatic Agreement.

Determination of Effect

Direct Effects

Item 21 Select the appropriate direct effect. Choose only one option.

NOTE: Pursuant to Section VI.D.2.a. of the Nationwide Programmatic Agreement, Applicants shall make a reasonable and good faith effort to identify above ground and archeological historic properties, including buildings, structures, and historic districts, that lie within the APE for direct effects. Such reasonable and good faith efforts may include a field survey where appropriate.

ADDITIONAL NOTE: Under Section VI.D.2.d. of the Nationwide Programmatic Agreement, an archeological field survey is required if an Indian tribe or NHO provides evidence that supports a high probability of the presence of intact archeological Historic Properties within the APE for direct effects.

Visual Effects

Item 22 Select the appropriate visual effect. Choose only one option.

NOTE: Section VI.D.1.a. of the Nationwide Programmatic Agreement requires the Applicant to review publicly available records to identify historic properties within the APE for visual effects: i) properties listed on the National Register; ii) properties formally determined eligible for listing by the Keeper of the National Register; iii) properties that the SHPO/THPO certifies are in the process of being nominated to the National Register; iv) properties previously determined eligible as part of a consensus determination of eligibility between the SHPO/THPO and a Federal Agency or local government representing the Department of Housing and Urban Development (HUD); and, v) properties listed in the SHPO/THPO Inventory that the SHPO/THPO has previously evaluated and found to meet the National Register criteria, and that are identified accordingly in the SHPO/THPO Inventory. Section VI.D.1.a also requires the Applicant to identify historic properties that have religious or cultural significance to Tribes and Native Hawaiian Organizations.

Determination of Effect Attachments

You are required to provide two attachments regarding the Determination of Effect: Areas of Potential Effect and Mitigation of Effect (if applicable).

Areas of Potential Effect Guidelines:

a. Describe the APE for direct effects and explain how this APE was determined.

b. Describe the APE for visual effects and explain how this APE was determined.

Mitigation of Effect Guidelines:

In the case where an Adverse Visual Effect or Adverse Direct Effect has been determined you must provide the following:

1. Copies of any correspondence and summaries of any oral communications with the SHPO/THPO and any consulting parties.

Describe any alternatives that have been considered that might avoid, minimize, or mitigate any adverse effects. Explain the Applicant’s conclusion regarding the feasibility of each alternative.

Tribal/NHO Involvement

(NOTE: This page may be copied for additional Tribes/NHOs contacted)

Item 1 Check Yes or No if Indian Tribes or Native Hawaiian Organizations (NHOs) have been identified that may attach religious and cultural significance to historic properties which might be affected by the undertaking within the APEs for direct and visual effects.

Items 2a & 2b Enter the TCNS Notification Number and the number of Tribes/NHOs contacted electronically or through an alternate system.

Item 3 If available, enter the ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from , by calling the FCC’s Forms Distribution Center at (800) 418‑3676, or from the FCC’s Fax Information System by dialing (202) 418-0177.

Item 4 Enter the Tribe/NHO name.

Items 5 through 9 Enter the name and title of the individual to contact in Items 5 through 9.

Items 10 & 11 Enter the date contacted (MM/DD/YYYY) and date replied (MM/DD/YYYY) and select the option that corresponds to the contact method and the response.

Tribal/NHO Involvement Attachments

You may be required to provide a Tribal/NHO Involvement attachment(s) (if applicable).

Tribal/NHO Involvement Attachment Guidelines

At an early stage in the planning process, the Nationwide Programmatic Agreement requires the Applicant to gather information from appropriate Indian Tribes or Native Hawaiian Organizations (“NHOs”) to assist in the identification of historic properties of religious and cultural significance to them. Describe measures taken to identify Indian Tribes and NHOs that may attach religious and cultural significance to historic properties that may be affected by the collocation within the Areas of Potential Effects (“APEs”) for direct and visual effects. If such Indian Tribes or NHOs were identified, list them and provide a summary of contacts by the FCC, the Applicant, or the Applicant’s representative. Provide copies of relevant documents, including correspondence. If no such Indian tribes or NHOs were identified, please explain.

Other Tribes/NHOs Contacted

(NOTE: This page may be copied for additional Tribal/NHOs)

Tribe/NHO Information/Contact Information

Item 1 If available, enter the ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from , by calling the FCC’s Forms Distribution Center at (800) 418‑3676, or from the FCC’s Fax Information System by dialing (202) 418-0177.

Items 2-15 Enter the name of the Tribe/NHO in Item 4. Enter the individual to contact in Items 3 through 6 as well as the title in Item 7. You may enter a post office box number in Item 8 or a street address in Item 9, or enter information for both items. Enter the city, state, and zip code in Items 10, 11, and 12. Refer to Appendix I, for a list of valid state, jurisdiction, and area abbreviations. Enter a telephone number, including area code, in Item 13. Enter the fax number (including area code) and e-mail address, if desired and available, in items 14 and 15.

Item 16 Select the preferred means of communication.

Dates & Response

Items 17 & 18 Enter the date contacted (MM/DD/YYYY) and date replied (MM/DD/YYYY) and select the option that corresponds to the contact method and the response.

Historic Properties

(NOTE: This page may be copied for additional historic properties)

Properties Identified

Item 1 Check Yes or No if any historic properties have been identified within the APEs for direct and visual effect.

NOTE: Section II.A.9. of the Nationwide Programmatic Agreement defines a “historic property” as: “Any prehistoric or historic district, site, building, structure, or object included on, or eligible for inclusion on, the National Register maintained by the Secretary of the Interior. This term includes artifacts, records, and remains that are related to and located within such properties. The term includes properties of traditional religious and cultural importance to an Indian tribe or Native Hawaiian Organization that meet the National Register criteria.”

Please note that historic units of the National Parks system are listed on the National Register, and that discontinuous units of national parks may be in different jurisdictions.

Item 2 Check Yes or No if the identification process located archaeological materials that would be directly affected, or sites that are of cultural or religious significance to Tribes/NHOs.

Item 3 Check Yes or No if there are more than 10 historic properties with the APEs for direct and visual effect. If ”Yes”, you are required to attach a Cultural Resources Report instead of completing items 4 through 10 of this section.

Historic Property

Items 4 & 5 Enter the property name and the SHPO site number, if any.

Property Address

Items 6 through 10 Enter a street address in Item 6. Enter the city, state, zip code and county/borough/parish in Items 7, 8, 9 and 10 respectively. Refer to Appendix I, for a list of valid state, jurisdiction, and area abbreviations.

Status & Eligibility

Item 11 Check Yes or No of the property is listed on the National Register and provide the source.

Item 12 Check Yes or No if the property is eligible for listing on the National Register and provide the source.

Item 13 Check Yes or No if the property is a National Historical Landmark.

Direct Effects

Item 14 Select the appropriate direct effect. Choose only one option.

NOTE: Pursuant to Section VI.D.2.a. of the Nationwide Programmatic Agreement, Applicants shall make a reasonable and good faith effort to identify above ground and archeological historic properties, including buildings, structures, and historic districts, that lie within the APE for direct effects. Such reasonable and good faith efforts may include a field survey where appropriate.

ADDITIONAL NOTE: Under Section VI.D.2.d. of the Nationwide Programmatic Agreement, an archeological field survey is required if an Indian Tribe or NHO provides evidence that supports a high probability of the presence of intact archeological Historic Properties within the APE for direct effects.

Visual Effects

Item 15 Select the appropriate visual effect. Choose only one option.

NOTE: Section VI.D.1.a. of the Nationwide Programmatic Agreement requires the Applicant to review publicly available records to identify within the APE for visual effects: i) properties listed on the National Register; ii) properties formally determined eligible for listing by the Keeper of the National Register; iii) properties that the SHPO/THPO certifies are in the process of being nominated to the National Register; iv) properties previously determined eligible as part of a consensus determination of eligibility between the SHPO/THPO and a Federal Agency or local government representing the Department of Housing and Urban Development (HUD); and, v) properties listed in the SHPO/THPO Inventory that the SHPO/THPO has previously evaluated and found to meet the National Register criteria, and that are identified accordingly in the SHPO/THPO Inventory. . Section VI.D.1.a also requires the Applicant to identify historic properties that have religious or cultural significance to Tribes and Native Hawaiian Organizations.

Historic Properties Attachments

Historic Properties Identified for Direct Effects Guidelines

a. List all properties identified within the APE for direct effects.

b. Provide the name and address (including U.S. Postal Service ZIP Code) of each property in the APE for direct effects, not listed in part “a”, that the Applicant considers to be eligible for listing in the National Register as a result of the Applicant’s research. For each such property, describe how it satisfies the criteria of eligibility (36 C.F.R. Part 63). For each property that was specifically considered and determined not to be eligible, describe why it does not satisfy the criteria of eligibility.

c. Describe the techniques and the methodology, including any field survey, used to identify historic properties within the APE for direct effects.⁵ If no archeological field survey was performed, provide a report substantiating that: i) the depth of previous disturbance exceeds the proposed construction depth (excluding footings and other anchoring mechanisms) by at least 2 feet; or, ii) geomorphological evidence indicates that cultural resource-bearing soils do not occur within the project area or may occur but at depths that exceed 2 feet below the proposed construction depth.

Historic Properties Identified for Visual Effects Guidelines

1. Provide the name and address (including U.S. Postal Service ZIP Code) of each property in the APE for visual effects that is listed in the National Register, has been formally determined eligible for listing by the Keeper of the National Register, or is identified as considered eligible for listing in the records of the SHPO/THPO, pursuant to Section VI.D.1.a. of the Nationwide Agreement.⁶

2. Provide the name and address (including U.S. Postal Service ZIP Code) of each Historic Property in the APE for visual effects, not listed in part “a”, identified through the comments of Indian Tribes, NHOs, local governments, or members of the public. Identify each individual or group whose comments led to the inclusion of a Historic Property in this attachment. For each such property, describe how it satisfies the criteria of eligibility (36 C.F.R. Part 63).

3. For any properties listed in part “a”, that the Applicant considers no longer eligible for inclusion in the National Register, explain the basis for this recommendation.

Local Government Involvement

(NOTE: This page may be copied for additional local government agencies)

Local Government Agency/Contact Information

Item 1 If available, enter the ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from , by calling the FCC’s Forms Distribution Center at (800) 418‑3676, or from the FCC’s Fax Information System by dialing (202) 418-0177.

Items 2-15 Enter the name of the local government agency in Item 2. Enter the name and title of the individual to contact in Items 3 through 7. You may enter a post office box number in Item 8 or a street address in Item 9, or enter information for both items. Enter the city, state, and zip code in Items 10, 11, and 12. Refer to Appendix I, for a list of valid state, jurisdiction, and area abbreviations. Enter a telephone number, including area code, in Item 13. Enter the fax number (including area code) and e-mail address, if desired and available, in items 14 and 15.

Item 16 Select the preferred means of communication.

Dates & Response

Items 17 & 18 Enter the date contacted (MM/DD/YYYY) and date replied (MM/DD/YYYY) and select the option that corresponds to the contact method and the response.

Additional Information

Item 19 Enter any information on local government’s role or interest. (Optional)

Local Government Involvement Attachment(s)

You may be required to provide a Local Government attachment(s).

Local Government Attachment Guidelines

a. If any local government has been contacted and invited to become a consulting party pursuant to Section V.A. of the Nationwide Programmatic Agreement, list the local government agencies contacted.   Provide a summary of contacts and copies of any relevant documents (e.g., correspondence or notices).

b. If a local government agency will be contacted but has not been to date, explain why and when such contact will take place.

Other Consulting Parties

(NOTE: This page may be copied for additional consulting parties)

Other Consulting Parties Contacted

Item 1 Check Yes or No if any other agency has been contacted and invited to become a consulting party. If “Yes”, complete items 2 through 20.

Consulting Party/Contact Information

Item 2 If available, enter the ten-digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available for downloading from , by calling the FCC’s Forms Distribution Center at (800) 418‑3676, or from the FCC’s Fax Information System by dialing (202) 418-0177.

Items 3-16 Enter the name of the consulting party in Item 3. Enter the name and title of the individual to contact in Items 4 through 8. Items 5, 7 and 8 are optional. You may enter a post office box number in Item 9 or a street address in Item 10, or enter information for both items. Enter the city, state, and zip code in Items 11, 12, and 13. Refer to Appendix I, for a list of valid state, jurisdiction, and area abbreviations. Enter a telephone number, including area code, in Item 14. Enter the fax number (including area code) and e-mail address, if desired and available, in items 15 and 16.

Item 17 Select the preferred means of communication.

Dates & Response

Items 18 & 19 Enter the date contacted (MM/DD/YYYY) and date replied (MM/DD/YYYY) and select the option that corresponds to the contact method and the response.

Additional Information

Item 20 Enter any information on consulting parties’ role or interest. (Optional)

Consulting Parties Attachment

You are required to provide a Public Notice attachment.

Public Notice Guidelines:

Provide copies of any relevant correspondence or other documentation used to invite public involvement in this project (e.g., legal notices, letters, or public meetings).

Designation of SHPO/THPO

Item 1 Based on the site of the tower/collation, designate the Lead State Historic Preservation Officer (SHPO) or Tribal Historic Preservation Officer (THPO) to review this filing. A list of the SHPOs can be found at: http://www.ncshpo.org/.

Item 2 If the SHPO/THPO requires sending this filing to a regional office, enter the appropriate person/office as an alternate SHPO/THPO. You may also designate other SHPOs/THPOs as additional recipients. If either or both of the APEs include other jurisdictions. In addition, use this item to list the National and State/Provincial Historic Preservation Agencies when either of the APEs includes another country.

Designation of SHPO/THPO Attachments

You may be required to provide State Specific Forms as additional attachments.

SHPO/THPO Specific Forms:

The lead SHPO/THPO reviewing this filing may require additional forms specific to it’s Section 106 review requirements.

Certification

By signing this form, the applicant certifies that the statements listed in this section are true, complete, correct, and made in good faith.

This section must be completed. To be acceptable for filing, applications must be signed in accordance with Part 1 of the FCC rules. The signor must be a person authorized to sign the application. Paper originals of applications must bear an original signature. On paper originals, neither rubber-stamped nor photocopied signatures are acceptable. For filers filing electronically via ULS, the electronic signature shall consist of the name of the person authorized to sign typed on the application as a signature.

Appendix I

STATE TABLE

Abbreviations for States, Jurisdictions, and Areas

AL Alabama

AK Alaska

AZ Arizona

AR Arkansas

CA California

CO Colorado

CT Connecticut

DE Delaware

DC District of Columbia

FL Florida

GA Georgia

GM Gulf of Mexico

HI Hawaii

ID Idaho

IL Illinois

IN Indiana

IA Iowa

KS Kansas

KY Kentucky

LA Louisiana

ME Maine

MD Maryland

MA Massachusetts

MI Michigan

MN Minnesota

MS Mississippi

MO Missouri

MT Montana

NE Nebraska

NV Nevada

NH New Hampshire

NJ New Jersey

NM New Mexico

NY New York

NC North Carolina

ND North Dakota

OH Ohio

OK Oklahoma

OR Oregon

PA Pennsylvania

RI Rhode Island

SC South Carolina

SD South Dakota

TN Tennessee

TX Texas

UT Utah

VT Vermont

VA Virginia

WA Washington

WV West Virginia

WI Wisconsin

WY Wyoming

AS American Samoa

CN Canada

GU Guam

MP Northern Mariana Islands

MX Mexico

PR Puerto Rico

UM U.S. Territories: (Baker Island, Howland Island,

Jarvis Island, Johston Atoll, Kingman Reef, Midway

Island, Navassa Island, Palmyra Atoll and Wake Island)

VI Virgin Islands

AA Armed Forces-Americas (excluding Canada)

AE Armed Forces-(Europe, Middle East, Africa,

Canada)

AP Armed Forces-Pacific

FCC Form 621 FCC Wireless Telecommunications Bureau Approved by OMB

Collocation (“CO”) Submission Packet 3060 – 1039

See instructions for

public burden estimates

General Information

1) (Select only one) ( ) NE – New UA – Update of Application WD – Withdrawal of Application
2) If this application is for an Update or Withdrawal, enter the file number of the pending application currently on file.	File Number:

Applicant Information

3) FCC Registration Number (FRN):

4) Name:

Contact Name

5) First Name:	6) MI:	7) Last Name:	8) Suffix:
9) Title:

Contact Information

10) P.O. Box:	And /Or	11) Street Address:
12) City:				13) State:	14) Zip Code:
15) Telephone Number: ( )			16) Fax Number: ( )
17) E-mail Address:

Consultant Information

18) FCC Registration Number (FRN):

19) Name:

Principal Investigator

20) First Name:	21) MI:	22) Last Name:	23) Suffix:
24) Title:

Principal Investigator Contact Information

25) P.O. Box:	And /Or	26) Street Address:
27) City:				28) State:	29) Zip Code:
30) Telephone Number: ( )			31) Fax Number: ( )
32) E-mail Address:

Professional Qualification

33) Does the Principal Investigator satisfy the Secretary of the Interior’s Professional Qualification Standards?	( ) Yes ( ) No
34) Areas of Professional Qualification: ( ) Archaeologist ( ) Architectural Historian ( ) Historian ( ) Architect ( ) Other (Specify) __________________________________________________

Additional Staff

35) Are there other staff involved who meet the Professional Qualification Standards of the Secretary of the Interior?

( ) Yes ( ) No

If “YES”, complete the following:

36) First Name:	37) MI:	38) Last Name:	39) Suffix:
40) Title:
41) Areas of Professional Qualification: ( ) Archaeologist ( ) Architectural Historian ( ) Historian ( ) Architect ( ) Other (Specify) __________________________________________________

This page may be copied to include additional staff.

Consultant Information Attachments required – See instructions for details.

Site Information

Tower Construction Notification System

1) TCNS Notification Number: ____________________________

Site Information

2) Positive Train Control Filing Subject to Expedited Treatment Under Program Comment: ( ) Yes ( ) No
3) Site Name:
4) Site Address:
5) Detailed Description of Project:
6) City:	7) State:	8) Zip Code:
9) County/Borough/Parish:
10) Nearest Crossroads:
11) NAD 83 Latitude (DD-MM-SS.S): ( ) N or ( ) S
12) NAD 83 Longitude (DD-MM-SS.S): ( ) E or ( ) W

Collocation Information

13) Antennas will be located on (Select One): ( ) Communications Tower (Select One): ( ) Guyed Lattice Tower ( ) Self-supporting Lattice ( ) Monopole ( ) Other (Describe): ______________________________________________________________ ( ) Non-Tower Structure (Describe Structure): ________________________________________________________________________________
14) Tower height above ground level (including top-mounted attachments such as lightning rods): ___________________ ( ) Feet ( ) Meters
15) Description of Antennas to be collocated (e.g. number, type, shape, dimensions, color): ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
16) Will the Antennas be placed at multiple levels on the structure? If “Yes”, describe placement: ____________________________________________________________________ ____________________________________________________________________________________________ If “No”, specify the height of collocation above ground: ___________________ ( ) Feet ( ) Meters	( ) Yes ( ) No
17) Structure Completion Year: _____________________ (YYYY) ( ) Check here if your year provided is approximate.
18) Has the Communications Tower or Non-Tower Structure been the subject of SHPO/THPO review? If “Yes”, specify the following: Company that made the submission: ______________________________________________________________ Date submitted: ______/______/______ SHPO/THPO Reference Number: _____________________	( ) Yes ( ) No
19) Is the Communications Tower or Non-Tower Structure eligible for listing on the National Register?	( ) Yes ( ) No

Site Information Attachments required – See instructions for details.

Collocation Status

20) Current Collocation Status (Select One):

( ) Construction and/or installation has not yet commenced

( ) Construction and/or installation has commenced, but is not completed

Construction and/or installation commenced on: _____/_____/_____

( ) Construction has been completed

Construction and/or installation commenced on: _____/_____/_____ Construction and/or installation completed on: _____/_____/_____

Determination of Effect

21) Direct Effects (Select One):

( ) No Historic Properties in Area of Potential Effects (APE)

( ) No Effect on Historic Properties in APE

( ) No Adverse Effect on Historic Properties in APE

( ) Adverse Effect on one or more Historic Properties in APE

22) Visual Effects (Select One):

( ) No Historic Properties in Area of Potential Effects (APE)

( ) No Effect on Historic Properties in APE

( ) No Adverse Effect on Historic Properties in APE

( ) Adverse Effect on one or more Historic Properties in APE

Determination of Effect Attachments required – See instructions for details.

Tribal/NHO Involvement

1) Have Indian Tribes or Native Hawaiian Organizations (NHOs) been identified that may attach religious and cultural significance to historic properties which may be affected by the undertaking within the APEs for direct and visual effects?	( ) Yes ( ) No
2a) Tribes/NHOs contacted through TCNS Notification Number: ___________________ Number of Tribes/NHOs: _________________ 2b) Tribes/NHOs contacted through an alternate system: Number of Tribes/NHOs: _________________

Tribe/NHO Contacted Through TCNS

3) Tribe/NHO FRN:

4) Tribe/NHO Name:

Contact Name

5) First Name:	6) MI:	7) Last Name:	8) Suffix:
9) Title:

Dates & Response

10) Date Contacted _____/_____/_____ 11) Date Replied _____/_____/_____

( ) No Reply

( ) Replied/No Interest

( ) Replied/Have Interest

( ) Replied/Other ______________________________________________________________________________________________

This page may be copied to include additional Tribes/NHOs contacted.

Tribal/NHO Involvement Attachments may be required – See instructions for details.

Other Tribes/NHOs Contacted

Tribe/NHO Information

1) FCC Registration Number (FRN):

2) Name:

Contact Name

3) First Name:	4) MI:	5) Last Name:	6) Suffix:
7) Title:

Contact Information

8) P.O. Box:	And /Or	9) Street Address:
10) City:				11) State:	12) Zip Code:
13) Telephone Number: ( )			14) Fax Number: ( )
15) E-mail Address:
16) Preferred means of communication: ( ) E-mail ( ) Letter ( ) Both

Dates & Response

17) Date Contacted _____/_____/_____ 18) Date Replied _____/_____/_____

( ) No Reply

( ) Replied/No Interest

( ) Replied/Have Interest

( ) Replied/Other ___________________________________________________________________________________________

This page may be copied to include additional Tribes/NHOs.

Historic Properties

Properties Identified

1) Have any historic properties been identified within the APEs for direct and visual effect?	( ) Yes ( ) No
2) Has the identification process located archaeological materials that would be directly affected, or sites that are of cultural or religious significance to Tribes/NHOs?	( ) Yes ( ) No
3) Are there more than 10 historic properties within the APEs for direct and visual effect? If “Yes”, you are required to attach a Cultural Resources Report in lieu of adding the Historic Property below.	( ) Yes ( ) No

Historic Property

4) Property Name:

5) SHPO Site Number:

Property Address

6) Street Address:
7) City:	8) State:	9) Zip Code:
10) County/Borough/Parish:

Status & Eligibility

11) Is this property listed on the National Register? Source: _______________________________________________________________________________________	( ) Yes ( ) No
12) Is this property eligible for listing on the National Register? Source: _______________________________________________________________________________________	( ) Yes ( ) No
13) Is this property a National Historic Landmark?	( ) Yes ( ) No

14) Direct Effects (Select One):

( ) No Effect on this Historic Property in APE

( ) No Adverse Effect on this Historic Property in APE

( ) Adverse Effect on this Historic Property in APE

15) Visual Effects (Select One):

( ) No Effect on this Historic Property in APE

( ) No Adverse Effect on this Historic Property in APE

( ) Adverse Effect on this Historic Property in APE

This page may be copied to include additional Historic Properties.

Historic Property Attachments required – See instructions for details.

Local Government Involvement

Local Government Agency

1) FCC Registration Number (FRN):

2) Name:

Contact Name

3) First Name:	4) MI:	5) Last Name:	6) Suffix:
7) Title:

Contact Information

8) P.O. Box:	And /Or	9) Street Address:
10) City:				11) State:	12) Zip Code:
13) Telephone Number: ( )			14) Fax Number: ( )
15) E-mail Address:
16) Preferred means of communication: ( ) E-mail ( ) Letter ( ) Both

Dates & Response

17) Date Contacted _____/_____/_____ 18) Date Replied _____/_____/_____

( ) No Reply

( ) Replied/No Interest

( ) Replied/Have Interest

( ) Replied/Other ___________________________________________________________________________________________

Additional Information

19) Information on local government’s role or interest (optional):

This page may be copied to include additional local government agencies.

Local Government Attachments required – See instructions for details.

Other Consulting Parties

Other Consulting Parties Contacted

1) Has any other agency been contacted and invited to become a consulting party?

( ) Yes ( ) No

Consulting Party

2) FCC Registration Number (FRN):

3) Name:

Contact Name

4) First Name:	5) MI:	6) Last Name:	7) Suffix:
8) Title:

Contact Information

9) P.O. Box:	And /Or	10) Street Address:
11) City:				12) State:	13) Zip Code:
14) Telephone Number: ( )			15) Fax Number: ( )
16) E-mail Address:
17) Preferred means of communication: ( ) E-mail ( ) Letter ( ) Both

Dates & Response

18) Date Contacted _____/_____/_____ 19) Date Replied _____/_____/_____

( ) No Reply

( ) Replied/No Interest

( ) Replied/Have Interest

( ) Replied/Other ___________________________________________________________________________________________

Additional Information

20) Information on other consulting parties’ role or interest (optional):

This page may be copied to include additional consulting parties.

Consulting Parties Attachments required – See instructions for details.

Designation of SHPO/THPO

1) Designate the Lead State Historic Preservation Officer (SHPO) or Tribal Historic Preservation Officer (THPO) based on the location of the tower/collation. 

SHPO/THPO

Name: ___________________________________________________________________________________________________________

2) You may also designate up to three additional SHPOs/THPOs if the APEs include multiple states. If the APEs include other countries, enter the name of the National Historic Preservation Agency and any state and provincial Historic Preservation Agency

SHPO/THPO Name: ________________________________________________________________________________________________

SHPO/THPO Name: ________________________________________________________________________________________________

SHPO/THPO Name: ________________________________________________________________________________________________

Designation of SHPO/THPO Attachments may be required – See instructions for details.

Certification

I certify that all representations on this FCC Form 621 Submission Packet and the accompanying attachments are true, correct, and complete.
Party Authorized to Sign
First Name:	MI:	Last Name:		Suffix:
Signature:			Date: _____/_____/_____
FAILURE TO SIGN THIS APPLICATION MAY RESULT IN DISMISSAL OF THE APPLICATION AND FORFEITURE OF ANY FEES PAID.
WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. Code, Title 18, Section 1001) AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, Section 312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, Section 503).

1 A “communications tower” is a structure built for the sole or primary purpose of supporting FCC licensed antennas and their associated facilities; other structures upon which antennas may be collocated are referred to as “non-tower structures.”

2 16 U.S.C. § 470(f).

3 Nationwide Programmatic Agreement for the Collocation of Wireless Antennas, 16 FCC Rcd 5574, 5575-5581 (WTB: March 16, 2001)(“Collocation Agreement”); see also Fact Sheet Regarding the Implementation of the Nationwide Programmatic Agreement with Respect to Collocating Wireless and Broadcast Facilities on Existing Towers and Structures, Notice, 67 Fed. Reg. 5282 (Feb. 5, 2002).

4 Section II.A.9. of the Nationwide Agreement defines a “historic property” as: “Any prehistoric or historic district, site, building, structure, or object included in, or eligible for inclusion in, the National Register maintained by the Secretary of the Interior. This term includes artifacts, records, and remains that are related to and located within such properties. The term includes properties of traditional religious and cultural importance to an Indian tribe or NHO that meet the National Register criteria.”

5 Pursuant to Section VI.D.2.a. of the Nationwide Programmatic Agreement, Applicants shall make a reasonable and good faith effort to identify above ground and archeological historic properties, including buildings, structures, and historic districts, that lie within the APE for direct effects. Such reasonable and good faith efforts may include a field survey where appropriate.

6 Section VI.D.1.a. of the Nationwide Programmatic Agreement requires the Applicant to review publicly available records to identify within the APE for visual effects: i) properties listed in the National Register; ii) properties formally determined eligible for listing by the Keeper of the National Register; iii) properties that the SHPO/THPO certifies are in the process of being nominated to the National Register; iv) properties previously determined eligible as part of a consensus determination of eligibility between the SHPO/THPO and a Federal Agency or local government representing the Department of Housing and Urban Development (HUD); and, v) properties listed in the SHPO/THPO Inventory that the SHPO/THPO has previously evaluated and found to meet the National Register criteria, and that are identified accordingly in the SHPO/THPO Inventory.

FCC Form 621 – Instructions

April 2014 - Page 21