PennDOT Engineering District [District]-##

[Response-Letter-Date]

Application No. [Application ID] County: [County-Name]

Status: [Application Status] SR: [State-Road] Segment: [Segment] Offset: [Offset]

[Applicant-Name]

[Applicant-Address-Line-1]

[Applicant-Address-Line-2]

[Applicant-City], [Applicant-State] [Applicant-Zip-Code]

Dear Applicant:

PennDOT has not received the signed and notarized document "Recording Copy" form (M-945 RC) with a check as requested within 30 days of conditional approval.  Therefore, your highway occupancy permit or supplement application number ___________, dated __________, will not be approved and the conditional approval is voided.

If still interested in pursuing a permit or supplement, a new application must be filed.  You are reminded that there is no approved highway occupancy permit or supplement associated with application number __________.

You may appeal this final decision by the Department under 2 Pa. C.S. Sections 501--508 (relating to practice and procedure of Commonwealth agencies), 1 Pa. Code Part II (relating to general rules of administrative practice and procedure) and 67 Pa. Code Chapter 491 (relating to procedures before the Department) by submitting a written request for a hearing within 30 days after the certified mailing date noted above, to the Administrative Docket Clerk, Office of Chief Counsel, Commonwealth Keystone Building, 400 North Street, 9th Floor, Harrisburg, Pennsylvania 17120-0096.

A filing fee in the amount of $________ as prescribed under Chapter 491 (relating to general procedures), made payable to the "Commonwealth of Pennsylvania", and a copy of this letter shall accompany each request.

If you have any questions regarding this matter, you may contact ____________________, District Permit Manager, at __________________.