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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. Is the project site within fives miles of any officially designated and publicly accessible federal, state, or local 9 Yes 9 No ✔ scenic or aesthetic resource? If Yes: Western New York Southtowns Scenic Byway, Sprague Brook Park 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.): State ___________________________________________________________________________________________________ Scenic Byway, County Park iii. Distance between project and resource: _____________________ 0, 2, 5 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_______________________________________ PRINT FORM Page 13 of 13