20150029 Ver 1_Mitigation Request to EEP_20150309

U.S. ARMY CORPS OF ENGINEERS
Wifmington District
Compensatorv Miti�ation Responsibilitv Trans#er Form
Permittee: NCDOT/ Attn: Richard Hancock . Action ID: SAW-2013-00453
Project Name: K-4908 (l-77•Dual Rest Area) County: Iredell
Instructions to Permittee: The Permittee must provide a copy of this form to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Ecosystem Enhancement Program (NCEEPj, who will then sign the form to verify the
transfer of the mltigation responsibility. Once the Sponsor has signed this form, it is the Permittee's responsibility to
ensure that to the U.S. Army Corps of Engineers (USACE) Project Manager identified on page two is in receipt of a signed
copy of this form before conducting authorized impacts, unless otherwise specified below. If more than one mitigation
Sponsor will be used to provide the mitigation associated with the permit, or if the impacts and/or the mitiga#ion will occur
in more than one 8-digit Hydrologic Unit Code (HUC), multiple forms will be attached to the permit, and the separate forms
for each Sponsor and/ar HUC must be provided to the appropriate mitigation Sponsors.
lnstructions to Sponsor: The Sponsor must verify that the mitigation requirements shown below are available at the
identified site. By signing below, the Sponsor is accepting full responsibility for the identified mitigation, regardiess of
whether or not they have received payment from the Permittee. Once the form is signed, the Sponsor must update the
appropriate ledger and provide a copy of the signed form to the Permittee and to the USACE Bank/In-Lieu Fee Program
Manager. The Sponsor must also comply with all reporting requirements established in their authorizing instrument.
Permitted Impacts and Compensatory Mitigation Requirements:
Permitted Impacts Requiring Mitigation* 8-digit HUC and Basin: 03040102, Yadkin River Basin
Stream Impacts {linear
Warm � Coo!
Wetland Impacts (acres)
Riparian Riparian
Cold Non-Riparian Coastal
Riverine Non-riverine
� 189 � � � � I
*If more than one mitigation sponsor will be used far the permit, only include impacts to be mitigated by this sponsor.
Stream Mitigation (credits)
Warm Cool Cold
378
HUC and Basin: 03040102, Yadkin River Basin
Wetland Mitigation (credits)
Riparian Riparian
Non-Riparian Coastal
Riverine Non-riverine
Mitigation Site Debited: NCEEP
(List the name of the bank to be debited. For umbrelfa banks, also list the specific site. Far NCEEP, list NCEEP. !f the NCEEP
acceptance letter identifies a specific site, also list the specific site to be debited).
Section to be completed by the Mitigation Sponsor
5tatement of Mitigation Liability Acceptance: I, Yhe undersigned, verify that I am authorized to approve mitigation
transactions for the Mitigation Sponsor shown below, and ! certify that the Sponsor agrees to accept full responsibility for
providing the mitigation identified in this document (see the table above), associated with the USACE Permittee and Action
ID number shown. I also verify that released credits (andJor advance credits for NCEEP), as approved by the USACE, are
currently available at the mitigation site identified above. Further, I understand that if the Sponsor fails to provide the
required compensatory mitigation, the USACE Wilmington District Engineer may pursue measures against the Sponsor to
ensure compliance associated with the mitigation requirements.
Mitigation Sponsor Na
of Sponsor's
Signature of Sponsor's
�
Represen#ative
���
313
re
Page 1 of 2 Form Updated 2 October, 2012

USACE Wilmington District
Compensatory Mitigation Responsibility Transfer Form, Page 2
Conditions for Transfer of Compensatory Mitigation Credit:
• Once this document has been signed by the Mitigation Sponsor and the USACE is in r�ceipt of the signed form, the
Permittee is no longer responsible for providing the mitigation identified in this form, though the Permittee remains
responsible for any other mitigation requirements stated in the permit conditions.
• Construction within jurisdictional areas authorized by the permit identified on page one of this form can begin only
after the USACE is in receipt of a copy of this document signed by the 5ponsor, confirming that the Sponsor has
accepted responsibility for providing the mitigation requirements listed herein. For authorized impacts conducted by
the North Carolina Department of Transportation (NCDOT), construction within jurisdictional areas may proceed upon
permit issuance; however, a copy of this form signed by the Sponsor must be provided to the USACE within 3U days of
permit issuance. NCDOT remains fully responsible for the mitigation until the USACE has received this form, confirming
that the Sponsor has accepted responsibiiity for providing the mitigation requirements listed herein.
• Signed copies of this document must be retained 6y the Permittee, Mitigation Sponsor, and in the USACE
administrative recards for both the permit and the Bank/ILF Instrument. It is the Permittee's responsibility to ensure
that the USACE Project Manager (address belowj is provided with a signed copy of this form.
� If changes are proposed to the type, amount, or location of mitigation after this form has been signed and returned to
the USACE, the Sponsor must obtain case-by-case approval from the USACE Project Manager and/or Narth Carolina
Interagency Review Team (NCIRT). If approved, higher mitigation ratios may be applied, as per current District
guidance and a new version of this form must be completed and included in the USACE administrative records for both
the permit and the BankJILF Instrument.
Comments/Additional Conditions:
This form is not valid unless signed by the mitigation Sponsor and USACE Project Manager. For questions regarding this
form or any of the conditions of the permit authorization, contac-t the Project Manager at the address below.
USACE Projed Manager: Steve Kichefski
USACE Field Office: Asheville Regulatory Field OfFice
Email:
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
�
Signature
Februarv 20. 2015
Date of Signature
Current Wilmington District mitigation guidance, including information on mitigation ratios, functiona! assessments, and
mitigation bank location and availability, and credit classifications {including stream temperature and wetland groupings) is
available at http://ribits.usace.armv.mil.
Page 2 of 2
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