Rev. 01-2010

       

           COMMONWEALTH OF PENNSYLVANIA

         ENVIRONMENTAL HEARING BOARD

 (717) 787-3483                                                2nd Floor – Rachel Carson State Office Building                                       Maryanne Wesdock

Telecopier: (717) 783-4738                                       400 Market Street, P.O. Box 8457                                                Acting Secretary to the Board

http://ehb.courtapps.com                                                Harrisburg, PA  17105-8457

 

 

 

           NOTICE OF APPEAL

 

1. Name, address and telephone number of Appellant:

 

 

 

2. Subject of your appeal:

            (a) Action of the Department for which review is sought (a copy must be attached):

 

 

            (b) The Department's official who took the action:

 

 

            (c) The location of the operation or activity which is the subject of the Department's                       action (municipality, county):

 

 

            (d) On what date and how you received notice of the Department's action:

 

 

3. Objections to the Department's action in separate, numbered paragraphs.  The objections may be factual or legal and must be specific.  If you fail to state an objection here, you may be barred from raising it later in your appeal.  Attach additional sheets, if necessary.

 

 

 

 

 

 

 

 

 

 

4. Specify any related appeal(s) now pending before the Board. If you are aware of any such appeal(s) provide that information.

 

 

The information submitted is true and correct to the best of my information and belief.

 

____________________________________________                                                                    Signature of Appellant or Appellant’s Counsel

 

Telephone No.:_______________________________

 

If you have authorized counsel to represent you, please supply the following information  (CORPORATIONS MUST BE REPRESENTED BY COUNSEL):

 

 

____________________________________                                                                                    Name (Type or Print)

 

____________________________________                                                                                    Address

 

____________________________________                       

 

____________________________________

 

 

____________________________________                                                                                    (Area Code)    Telephone Number

 

 

 

THIS FORM AND THE PROOF OF SERVICE MUST BE RECEIVED BY THE ENVIRONMENTAL HEARING BOARD WITHIN 30 DAYS AFTER YOUR RECEIPT OF NOTICE OF THE ACTION OF THE DEPARTMENT THAT YOU ARE APPEALING.  MAIL OR HAND-DELIVER YOUR APPEAL AND PROOF OF SERVICE TO:

ENVIRONMENTAL HEARING BOARD

2nd Floor, Rachel Carson State Office Building

400 Market Street, P.O. Box 8457

Harrisburg, PA  17105-8457

 

You may wish to send your appeal to the Environmental Hearing Board by certified mail, return receipt, so that you know your appeal was received by it within the required time.

 

 

TDD users please contact the Pennsylvania Relay Service at 1-800-654-5984.  If you require an accommodation or this information in an alternative form, please contact the Secretary to the Board at 717-787-3483.

PROOF OF SERVICE

 

__________________________________________ (Appellant or Appellant’s Counsel, if appellant is represented by an attorney) hereby certifies that a copy of the notice of appeal, was on  _________________________, served upon

                 (date)

 

 

□ The Office of Chief Counsel of                                           □ first class mail, postage

    the Department or agency taking              via                      pre-paid

    the action appealed.                                                                        □ overnight delivery

            □ personal delivery

 

AND

 

□ The officer of the Department                                           □  first class mail, postage

    who took the action being                          via                       pre-paid             

    appealed.                                                                             □  overnight delivery

            □  personal delivery

 

AND

 

            If your appeal is from the Department’s issuance of a permit, license, approval, or certification to another person,

 

 

□ The recipient of the permit,                                                             □  first class mail, postage

    license, approval, or                                               via                         pre-paid    

    certification.                                                                                     □  overnight delivery

             □  personal delivery

 

                                                            AND

 

Where applicable, the following:

q       Any affected municipality, its municipal authority, and the proponent of the decision, where applicable, in appeals involving a decision under Sections 5 or 7 of the Sewage Facilities Act, 35 P.S. §§ 750.5, 750.7;

q       The mining company in appeals involving a claim of subsidence damage or water loss under the Bituminous Mine Subsidence and Land Conservation Act, 52 P.S. § 1406.1 et seq.;

q       The well operator in appeals involving a claim of pollution or diminution of a water supply under Section 208 of the Oil and Gas Act, 58 P.S. § 601.208;

q       The owner or operator of a storage tank in appeals involving a claim of an affected water supply under Section 1303 of the Storage Tank and Spill Prevention Act, 35 P.S. § 6021.1303.

__________________________________

 

__________________________________

 

__________________________________

     Signature (Appellant or Appellant’s

     Counsel, if appellant is represented

      by an attorney)