**The copy of the FCC FORM 620 which follows this page has not been
approved for use by the Office of Management and Budget ("OMB"). Text in
the headers and footers of the form has been marked with the
strikethrough feature to indicate that the form has not yet been
approved.**

**When OMB has granted approval for the public to use FCC Form 620, the
Commission will issue a public notice stating that such approval has
been granted and attaching the approved version of the FCC Form 620. (An
approved copy of the FCC Form 621 will also be attached to the public
notice and released at that time.)**

**ATTACHMENT 3**

**New Tower ("NT") Submission Packet**

**FCC FORM 620**

## Introduction

The **NT Submission Packet** is to be completed by or on behalf of
Applicants to construct new antenna support structures by or for the use
of licensees of the Federal Communications Commission ("FCC"). **The
Packet (including Form 620 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")**[^1] **prior to
beginning construction 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") 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).[^2]

**[Exclusions and Scope of Use]{.underline}**

**The NT Submission Packet should not be submitted for undertakings that
are excluded from Section 106 Review.** The categories of new tower
construction that are excluded from historic preservation review under
Section 106 of the NHPA are described in Section III of the Nationwide
Agreement.

Where an undertaking 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 NT Submission Packet is to be used only for the construction of
new antenna support structures.** Antenna collocations that are subject
to Section 106 review should be submitted using the Collocation ("CO")
Submission Packet (FCC Form 621).

**[General Instructions: NT Submission Packet]{.underline}**

Fill out the answers to Questions 1-5 on Form 620 and provide the
requested attachments. Attachments should be numbered and provided in
the order described below.

For ease of processing, provide the Applicant's Name, Applicant's
Project Name, and Applicant's Project Number in the lower right hand
corner of each page of Form 620 and attachments.[^3]

#### **Applicant Information**

### Full Legal Name of Applicant: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name and Title of Contact Person:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address of Contact Person (including Zip Code):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-mail address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2. Applicant\'s Consultant Information**

Full Legal Name of Applicant\'s Section 106 Consulting Firm:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Principal Investigator:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title of Principal Investigator:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Investigator's Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State
\_\_\_\_\_\_\_\_\_\_\_ Zip Code \_\_\_\_\_\_\_\_\_\_

Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Fax:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

E-mail Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Does the Principal Investigator satisfy the Secretary of the Interior's
Professional Qualification Standards?[^4] YES / NO.

Areas in which the Principal Investigator meets the Secretary of the
Interior's Professional Qualification Standards:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other "Secretary of the Interior qualified" staff who worked on the
Submission Packet (provide name(s) as well as well as the area(s) in
which they are qualified):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3. Site Information**

a.  Street Address of Site:
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###### City or Township: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> County / Parish: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ State:
> \_\_\_\_ Zip Code: \_\_\_\_\_\_\_\_\_\_\_\_

b.  Nearest Cross Roads: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ /
    \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

c.  NAD 83 Latitude/Longitude coordinates (to tenth of a second):

N \_\_\_° \_\_\_' \_\_\_.\_"; W \_\_\_° \_\_\_' \_\_\_.\_"

d.  Proposed tower height above ground level:[^5] \_\_\_\_\_\_ feet;
    \_\_\_\_\_\_ meters

e.  Tower type:

> guyed lattice tower self-supporting lattice monopole
>
> other (briefly describe tower)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**4. Project Status:**[^6]

a.  \[ \] Construction not yet commenced;

b.  \[ \] Construction commenced on \[date\] \_\_\_\_\_\_\_\_\_\_\_\_\_;
    or,

c.  \[ \] Construction commenced on \[date\] \_\_\_\_\_\_\_\_\_ and was

completed on \[date\] \_\_\_\_\_\_\_\_\_\_.

**5. Applicant's Determination of Effect:**

**a. Direct Effects** (check one):

i.  \[ \] No Historic Properties in Area of Potential Effects ("APE")
    for direct effects;

ii. \[ \] "No effect" on Historic Properties in APE for direct effects;

iii. \[ \] "No adverse effect" on Historic Properties in APE for direct
     effects;

iv. \[ \] "Adverse effect" on one or more Historic Properties in APE for
    direct effects.

**b. Visual Effects** (check one):

i.  \[ \] No Historic Properties in Area of Potential Effects ("APE")
    for visual effects;

ii. \[ \] "No effect" on Historic Properties in APE for visual effects;

iii. \[ \] "No adverse effect" on Historic Properties in APE for visual
     effects;

iv. \[ \] "Adverse effect" on one or more Historic Properties in APE for
    visual effects.

**[Certification and Signature]{.underline}**

> I certify that all representations on this FCC Form 620 and the
> accompanying attachments are true, correct, and complete.
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Signature Date
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Printed Name Title

**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).**

**[Attachments]{.underline}**

**Provide the following attachments in this order and numbered as
follows:**

**Attachment 1. Résumés / Vitae.**

Provide a current copy of the résumé 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 the Submission
Packet for this proposed facility.

**Attachment 2. Additional Site Information**

Describe any additional structures, access roads, utility lines, fences,
easements, or other construction planned for the site in conjunction
with the proposed facility.

**Attachment 3. Tribal and NHO Involvement**

At an early stage in the planning process, the Nationwide 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 undertaking within the Areas of
Potential Effects ("APE") **for direct and visual effects**. If such
Indian tribes or NHOs were identified, list them and provide a summary
of contacts by either 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.

**Attachment 4. Local Government**

**a.** Has any local government agency been contacted and invited to
become a consulting party pursuant to Section V.A. of the Nationwide
Agreement? If so, 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.

**Attachment 5. Public Involvement**

Describe measures taken to obtain public involvement in this project
(*e.g.*, notices, letters, or public meetings). Provide copies of
relevant documentation.

**Attachment 6. Additional Consulting** **Parties**

List additional consulting parties that were invited to participate by
the Applicant, or independently requested to participate. Provide any
relevant correspondence or other documents.

**Attachment 7. Areas of Potential Effects**

**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.

**Attachment 8. Historic Properties Identified in the APE for Visual
Effects**

**a.** 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.[^7]

**b.** 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 Attachment 8a, 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).

**c.** For any properties listed on Attachment 8a that the Applicant
considers no longer eligible for inclusion in the National Register,
explain the basis for this recommendation.

**Attachment 9. Historic Properties Identified in the APE for Direct
Effects**

**a.** List all properties identified in Attachment 8a or 8b that are
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
Attachment 9a, 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.[^8] 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.[^9]

**Attachment 10. Effects on Identified Properties**

For each property identified as a Historic Property in Attachments 8 and
9:

**a.** Indicate whether the Applicant believes the proposed undertaking
would have a) no effect; b) no adverse effect; or, c) an adverse effect.
Explain how each such assessment was made. Provide supporting
documentation where necessary.

**b.** Provide copies of any correspondence and summaries of any oral
communications with the SHPO/THPO.

**c.** 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.

**Attachment 11. Photographs**

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 (*see* Item 12 below) or text, and dated; the
focal length of the lens 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.

a.  Photographs taken from the tower site showing 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 proposed tower.

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

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

d.  Aerial photos of the APE for visual effects, if available.

**Attachment 12. Maps**

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

a.  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.

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

c.  Show the locations of each property listed in Attachments 8 and 9.

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

**Attribution and Bibliographic Standards.** All reports included in the
Submission Packet should be footnoted and contain a bibliography of the
sources consulted.

a.  Footnotes may be in a form generally accepted in the preparer's
    profession so long as they identify the author, title, publisher,
    date of publication, and pages referenced for published materials.
    For archival materials/documents/letters, the citation should
    include author, date, title or description and the name of the
    archive or other agency holding the document.

b.  A bibliography should be appended to each report listing the sources
    of information consulted in the preparation of the report. The
    bibliography may be in a form generally accepted in the preparer's
    profession.

**FCC NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE
PAPERWORK REDUCTION ACT**

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 provided in the application to determine whether
approving this application is in the public interest. If we believe
there may be a violation or potential violation of a FCC statute,
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; (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. In addition, all information provided in this form
will be available for public inspection.

If you owe a past due debt to the federal government, any information
you provide may also be disclosed to the Department of Treasury
Financial Management Service, other federal agencies and/or your
employer to offset your salary, IRS tax refund or other payments to
collect that debt. The FCC may also provide this information to these
agencies through the matching of computer records when authorized.

If you do not provide the information requested on this form, the
application may be returned without action having been taken upon it or
its processing may be delayed while a request is made to provide the
missing information. Your response is required to obtain the requested
authorization.

We have estimated that each response to this collection of information
will take an average of .50 to 10 hours. Our estimate includes the time
to read the instructions, look through existing records, gather and
maintain the 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, Paperwork Reduction
Project (3060-1039), Washington, DC 20554. We will also accept your
comments via the Internet if your send them to Judith-B.Herman@fcc.gov.
Please DO NOT SEND COMPLETED APPLICATIONS TO THIS ADDRESS. Remember -
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
of if we fail to provide you with this notice. This collection has been
assigned an OMB control number of 3060-1039.

[^1]: 16 U.S.C. § 470f.

[^2]: 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
    Native Hawaiian Organization that meet the National Register
    criteria."

[^3]: Some attachments may contain photos or maps on which this
    information can not be provided.

[^4]: 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
    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
    Agreement encourages, but does not require, use of
    Secretary-qualified professionals to identify historic properties
    within the APE for indirect effects. *See* Nationwide Agreement, §§
    VI.D.1.d, VI.D.1.e, VI.D.2.b, VI.E.5.

[^5]: Include top-mounted attachments such as lightning rods.

[^6]: Failure to provide the Submission Packet and complete the review
    process under Section 106 of the NHPA prior to beginning
    construction may violate Section 110(k) of the NHPA and the
    Commission's rules. *See* Section X of the Nationwide Agreement.

[^7]: Section VI.D.1.a. of the Nationwide 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.

[^8]: Pursuant to Section VI.D.2.a. of the Nationwide 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.

[^9]: Under Section VI.D.2.d. of the Nationwide Agreement, an
    archeological field survey is required even if one of these
    conditions applies, 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.