20140090 Ver 6_Modifications_20191008

Staff Review
Does this application have all the attachments needed to accept it into the review process?
r Yes r No
ID#* Version* 6
20140090
Is this project a public transportation project?* r Yes
r No
Is this a DOT r Yes r No
project?*
Reviewer List:*
Select Reviewing Office:*
Submittal Type:*
Modifications
Dave Wan ucha:eads\djwanucha
Winston-Salem Regional Office - [phone]
Does this project require a request for payment to be sent?*
r
Yes
c:
No

Project Submittal Form
Please note: fields marked with a red asterisk below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type: r New Project
r Pre -Application Submittal
r More Information Response
r Other Agency Comments
r For the Record Only (Courtesy Copy)
r Stream or Buffer Appeal
New Project - Please check the new project type if you are trying to submit a new project that needs an official approval
decision.
Pre -Application Submittal - Please check the pre -application submittal if you just want feedback on your submittal and
do not have the expectation that your submittal will be considered a complete application requiring a formal decision.
More Information Response - Please check this type if you are responding to a request for information from staff and
you have and ID# and version for this response.
Other Agency Comments - Please check this if you are submitting comments on an existing project.
Project Contact Information
Name: Kristi Lynn Carpenter for Carla Dagnino
Who is subrritting the information?
Email Address: [e-mail]
Project Information
Project Name: US 158 (U-2579B)
Is this a public transportation project?
r Yes
r No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
r Yes r No r Unknown
TIP#: WBS#:
U-2579 34839.2.10
(Applies to DOT projects only)
County (ies)
Forsyth
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach docurrent
U-2579B Permit Renewal and Modification Forsyth
2.87MB
September 18 2019.pdf
Only pdf or lore files are accepted.
Describe the attachments:
Original submitted via email.

rJ By checking the box and signing box below, I certify that:
• I have given true, accurate, and complete information on this form;
• I agree that submission of this form is a "transaction" subject to Chapter 66, Article 40 of the NC General Statutes (the
"Uniform Electronic Transactions Act")
• I agree to conduct this transaction by electronic means pursuant to Chapter 66, Article 40 of the NC General Statutes
(the "Uniform Electronic Transactions Act');
o I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature; AND
o I intend to electronically sign and submit the online form."
Signature:
C1{� /z7 �7rd C }� t�YrtrRt
Submittal Date: Is filled in autorratically.