20150621 Ver 1_More Info Received_20150625

Agent Authorization Form
Please print:
Property Owner:
Property Owner:
The undersigned, registered property owners of the above noted property, do hereby authorize
Equinox Environmental
Hunter Terrell , of Conultation and Desiqn, Inc.
(Contractor / Agent) (Name of consulting firm)
to act on my behalf and, take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
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Telephone: m
N 2 5 2015
We hereby certify the above information submitted in this application is true and accurate to
best of our knowledge. 401 8 B- WFAER PER IWT7. N�
Autho ized Sign ture Authorized Signature
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Date: r+ Date:

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5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or ❑x Yes ❑ No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act ❑ Yes ❑X No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted.
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
North Carolina Natural Heritage Data.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? I ❑ Yes ❑X No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
NOAA Essential Fish Habitat Mapper v3.0- Accessed February 26, 2014 (http: / /www. habitat. noaa. gov / protection /efh /habitatmapper.htm1)
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation . ❑ Yes ❑X No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
State Historic Preservation Office HPOWEB GIS Service- Accessed June 10, 2015 (http: / /gis.ncdcr.gov/hpowebn.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA- designated 100 -year floodplain?
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
Floodplain Mapping Program GIS Data- Downloaded 12/2014
❑ Yes X❑ No
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Applicant/Agent's Printed Name Applicant/Agent's Signature Date
(Agent's signature is valid only if an authorization
letter from the applicant is provided.)
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��N 2 5 2015
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