HomeMy WebLinkAbout20240558 Ver 1_ePCN Application_20240412DWR
Division of Water Resources
Pre -Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
October 2, 2023 Ver 4.3
Initial Review
Has this project met the requirements for acceptance in to the review process?
Yes No
Is this project a public transportation project?*
Yes No
Charge only if needed
Does this project involve maintenance dredging funded by the Shallow Draft Navigation Channel Dredging and Aquatic Weed Fund or involve the distribution ortransmission ofenergy or
fuel, including natural gas, diesel, petroleum, or electricity?
Yes No
BIMS # Assigned
Versiorl
20240558
1
Is a payment required for this project?*
No payment required
What amount is owed?*
Fee received
$240.00 $570.00
Fee needed - send electronic notification
$323.00 $767.00
Reviewing Office*
Select Project Reviewer*
Raleigh Regional Office - (919) 791-4200
Zachary Thomas:zacharythomas
Information for Initial Review
1 a. Name of project:
DG Market - Wilsons Mills
1 a. Who is the Primary Corl
Mark Zawadski
1 b. Primary Contact Eni
1 c. Primary Contact Phone:*
mzawadski@zarembagroup.com
(216)226-2124
Date Submitted
4/12/2024
Nearest Body of Water
Poplar Creek
Basin
Nauss
Water Classification
WS-IV NSW
Site Coordinates
Latitude: Longitude:
35.577765 -78.347410
A. Processing Information
Is this project connected with ARPA funding?
Yes No
County (or Counties) where the project is located:
Johnston
Is this a NCDMS Project
Yes No
Is this project a public transportation project?*
Yes No
Ia. Type(s) of approval sought from the Corps:
Section 404 Permit (wetlands, streams and waters, Clean Water Act)
Section 10 Permit (navigable waters, tidal waters, Rivers and Harbors Act)
Has this PCN previously been subri
Yes
No
I b. What type(s) of permit(s) do you wish to seek authorization?
Nationwide Permit (NWP)
Regional General Permit (RGP)
Standard (IP)
1c. Has the NWP or GP number been verified by the Corps?
Yes No
Nationwide Permit (NWP) Number: 18 - Minor Discharges
NWP Numbers (for multiple NWPS):
1 d. Type(s) of approval sought from the DWR:
401 Water Quality Certification - Regular
Non-404 Jurisdictional General Permit
Individual 401 Water Quality Certification
le. Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification:
For the record only for Corps Permit:
If. Is this an after -the -fact permit application? *
Yes No
Ig. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
Yes No
fig. Is payment into a mitigation bank or in -lieu fee program proposed for mitigation of impacts?
Yes No
I h. Is the project located in any of NC's twenty coastal counties?
Yes No
1j. Is the project located in a designated trout watershed?
Yes No
B. Applicant Information
1 d. Who is applying for the permit?
Owner Applicant (other than owner)
le. Is there an Agent/Consultant for this project?
Yes No
2. Owner Information
2a. Name(s) on recorded deed:
Clifton Earl Ryan
2b. Deed book and page no.:
401 Water Quality Certification - Express
Riparian Buffer Authorization
2c. Contact Person:
Guy Lampe - 1953 Company, LLC
2d. Address
Street Address
225 E. Peedin Road
Address Line 2
city State I Province / Region
Smithfield NC
Postal / Zip Code Country
27577 USA
Yes No
Yes No
2e. Telephone Number:
(919)934-3041
2g. Email Address:*
guyl@lampemanagement.com
3. Applicant Information (if different from owner)
3a. Name:
Mark Zawadski
3b. Business Name:
Zaremba Group, LLC
3c. Address
Street Address
14600 Detroit Ave
Address Line 2
Suite 1500
city
Lakewood
Postal / Zip Code
44107
3d. Telephone Number:
(216)226-2124
3f. Email Address:*
mzawadski@zarembagroup.com
4. Agent/Consultant (if applicable)
4a. Name:
Timothy O'Halloran, PWS
4b. Business Name:
ECS Southeast, LLC
4c. Address
Street Address
1812 Center Park Drive
Address Line 2
Suite D
city
Charlotte
Postal I Zip Code
28217
4d. Telephone Number:
(980)920-9615
4f. Email Address:*
tohalloran@ecslimited.com
C. Project Information and Prior Project History
-1. Project Information
1b. Subdivision name:
(if.ppropriat.)
1c. Nearest municipality / town:
Smithfield, NC
2. Project Identification
2a. Property Identification Number:
169610-35-8824
2f. Fax Number:
State / Province / Region
OH
Country
USA
3e. Fax Number:
State / Province I Region
NC
Country
USA
4e. Fax Number:
2b. Property size:
1.62
2c. Project Address
Street Address
4052 Wilsons Mills Road
Address Line 2
city
Smithfield
Postal / Zip Code
27577
3. Surface Waters
3a. Name of the nearest body of water to proposed project:
Poplar Creek
3b. Water Resources Classification of nearest receiving water:
WS-IV; NSW
3c. What river basin(s) is your project located in?*
Neuse
3d. Please provide the 12-digit HUC in which the project is located.
030202011105
4. Project Description and History
State / Province / Region
NC
Country
USA
4a. Describe the existing conditions on the site and the general land use in the vicinity ofthe project at the time ofthis application: *
The subject property consists of approximately 1.62 acres of undeveloped forested land. North of the project boundary is Main Street and Uzzles Pond Road, followed by single family
residences, maintained fields, forested areas, and agricultural land; east of the project boundary is Main Street, followed by single family residences and agricultural land; south of the
project boundary is Wilson's Mills Road, followed single family residences, undeveloped forested land, and HWY 70 E; west of the project boundary is a continuation ofWilson's Mills
Road, commercial development, and a development project at the corner of Wilson's Mills Road and Selco Road.
4b. Have Corps permits or DWR certifications been obtained for this project (including all prior phases) in the past? *
Yes No Unknown
4f. List the total estimated acreage of all existing wetlands on the property:
0.489
4g. List the total estimated linear feet of all existing streams on the property:
151
4h. Explain the purpose of the proposed project:
The purpose of the project is to construct a commercial retail store for Dollar General Market, to provide the public with access to goods.
4i. Describe the overall project in detail, including indirect impacts and the type of equipment to be used: *
The proposed project would develop the site with a commercial retail store for Dollar General Market. The total area of the facility would be 12,480 square feet. The development would
include a driveway along the northern property boundary that connects to Main Street. The driveway would include a single lane entrance and a dual -lane exit with left and right turning
lanes for safe entry and exit on and off the site. A second driveway would be located along the southern property boundary that connects to Wilson's Mills Road, this driveway would also
include a single lane entrance and a dual -lane exit with left and right turning lanes for safe entry and exit on and off the site. A retaining wall would be constructed adjacent to the southern
driveway to minimize erosion and impacts to downstream water quality. The development would also include adequate parking for employees and customers. Additionally, a wet pond for
stormwater management would be constructed within the southeastern portion of the site to pretreat stormwater prior to discharge.
ECS identified one stream (Potential Stream 1) and three wetlands (Potential Wetlands 1 through 3) within the site boundaries during the wetland delineations that were conducted on April
21, 2023 and December 29, 2023. The eastern portion of the site was verified by USACE under Action ID. SAW-2023-01249, and a Delineation Concurrence was received on September
15, 2023 (see Attachment A). Following verification, the project study area was extended to the west. A revised Preliminary Jurisdictional Determination Package is included in this
submittal as Attachment B.
The proposed project would result in 0.081 acre (3,554 sq. ft.) of permanent impacts to Welland 1, due to grading/fill associated with the construction ofthe commercial facility and
impervious pavement.
The proposed project would result in 0.016 acre (687 sq. ft.) of permanent impacts to Welland 2, due to grading associated with the wet pond for stormwater control measures. The lowest
portion of the wet pond will not be located within Welland 2.
The proposed project would result in 0.011 acre (490 sq. ft.) of temporary impacts to Wetland 1, due to temporary workspace needed during construction in order to safely and accurately
grade and stabilize slopes according to site plans. This workspace will also be used to construct the retaining wall which will minimize soil erosion and minimize impacts to downstream
water quality. Prior to construction start, timber matting or a similar material will be placed on the wetland to minimize disturbance and rutting. The matting will be removed upon
construction completion to allow the wetland to return to natural conditions.
The proposed project would result in 23 linear feet (0.002 acre) of temporary impacts to Stream 1, due to a cofferdam which would utilized to install riprap within the streambed. The
cofferdam shall not impede the flow of the stream in any way. The cofferdam will be formed by placing riprap, sandbags, sheet metal or wood planks in a semicircle around the proposed
work area. Height of the cofferdam will be adequate to keep water from overtopping the dam and flooding the work area. Water in the work area shall be pumped to an approved
dewatering practice. Once adequately dewatered, in -stream construction may begin from the first bank and proceed to the centerline of the stream. If a full stream crossing is required, all
disturbed areas shall be stabilized in accordance with the approved plan prior to dismantling and reconstructing the cofferdam on the opposite bank. The riprap will be keyed into the
stream bed and not exceed the top of stream bed or change the existing grade of the stream. See Sheet C3.01 on the attached Site Plans for details of the cofferdam.
The project is located in the Neuse River Basin and is subject to the NC Riparian Buffer Protection Program. The proposed project would impact 245 square feet ofthe Zones 1 buffer and
279 square feet of the Zone 2 buffer due to the southern driveway that provides access entry/exit to Wilson's Mills Road. The access for the project was designed to provide the safest and
most efficient traffic flow possible. The southern driveway on Wilson's Mills Road is a critical component to achieving this. Wilson's Mills Road is the primary throughfare through the Town
and provides the traffic capacity necessary for the project. Almost all traffic to the property will be using Wilson's Mills Road for ingress and egress. Main Street is a narrow, low volume
road with steeper grades, and close to a railroad crossing, all of which presents safety concerns. Therefore, Wilsons Mill's Road provides the safest access option. The Main Street access
will primarily serve tractor trailer deliveries, trash, and vendor deliveries. One of the main reasons for the two driveways is to keep passenger vehicle and truck vehicles separate for safety
reasons. The parking lot is also not wide enough to provide a wide turn radius for large trucks to turn around, and will therefore need the second driveway to exit. Based on these reasons,
the two access points are needed for safety and efficiency.
In addition, the driveway on Wilson's Mills Road is required to be located in this location to provide the greatest separation distance from the intersection (approximately 310 feet). The
allows the road widening and new turn lane to be designed properly so that there are no safety conflicts with the existing intersection. The access on Wilson's Mills Road will also be
shared with the adjacent property. This will not only improve safety and traffic flow for future development, but also eliminate the need for an extra driveway on Wilson's Mills Road and
associated environmental impacts that would have otherwise been needed.
Impact Exhibits depicting the wetland and stream impacts are included as Attachment C in the attached supporting documents
The development would be constructed via standard construction procedures. Proper erosion and sediment control measures will be utilized and maintained throughout the duration ofthe
project. Typical materials and machinery will be used on -site during the construction process.
5. Jurisdictional Determinations
5a. Have the wetlands or streams been delineated on the property or proposed impact areas?*
Yes
No
Comments:
ECS conducted a wetland delineation on April 21, 2023 and December 29, 2023.
5b. If the Corps made a jurisdictional determination, what type of determination was made?
Preliminary Approved Not Verified Unknown N/A
Corps AID Number:
A portion of the site has been verified under Action ID. SAW-2023-01249. A revised PJD request
package is included as part of this submittal.
5c. If 5a is yes, who delineated the jurisdictional areas?
Name (if known): Michelle Savage-Measday, PWS
Agency/Consultant Company: ECS Southeast, LLC
Other:
6. Future Project Plans
6a. Is this a phased project?*
Unknown
Yes No
Are any other NWP(s), regional general permit(s), or individual permits(s) used, or intended to be used, to authorize any part of the proposed project or related activity?
This is a single and complete project. The project is not part of a larger planned development.
D. Proposed Impacts Inventory
1. Impacts Summary
1 a. Where are the impacts associated with your project? (check all that apply):
Wetlands Streams -tributaries
Open Waters Pond Construction
2. Wetiand Impacts
Buffers
2al Reason (?) _1
2b. Impact type* (?) ]2c.
Type ofW.*
d. W. name
I
2f. Type of Jurisdicition
I (?)
2g. Impact
area
Grading/Fill 1p
��eadwater
Forest
I
Both
Grading/Fill 1P
FIated Wetlands
Wetland 2
Both
Temporary Workspac-
Fad -ter Forest
a
tland 1 ���]Both
2g. Total Temporary Wetland Impact
0.011
2g. Total Wetland Impact
0.108
2g. Total Permanent Wetland Impact
0.097
2i. Comments:
Mitigation is not proposed for the permanent wetland impacts because the total permanent impacts are below the required 0.1 acre mitigation threshold.
3. Stream Impacts
3a. Reason for impa
3c. Type of impact*
3e. Stream Type*
(?)
3f. Type of
Jurisdiction
3h. Impact
length
Stormwater Outfall 71�]
Rip Rap Fill J
Stream 1
Both
31. Total jurisdictional ditch impact in square feet:
0
3i. Total permanent stream impacts:
0
3i. Total stream and ditch impacts:
23
3i. Total temporary stream impacts:
23
3j. Comments:
The proposed project would result in 23 linear feet (0.002 acre) of temporary impacts to Stream 1, due to a cofferdam which would utilized to install
riprap within the streambed. The cofferdam shall not impede the flow of the stream in any way. The cofferdam will be formed by placing riprap,
sandbags, sheet metal or wood planks in a semicircle around the proposed work area. Height of the cofferdam will be adequate to keep water from
overtopping the dam and flooding the work area. Water in the work area shall be pumped to an approved dewatering practice. Once adequately
dewatered, in -stream construction may begin from the first bank and proceed to the centerline of the stream. If a full stream crossing is required, all
disturbed areas shall be stabilized in accordance with the approved plan prior to dismantling and reconstructing the cofferdam on the opposite bank. The
riprap will be keyed into the stream bed and not exceed the top of stream bed or change the existing grade of the stream. See Sheet C3.01 on the
attached Site Plans for details of the cofferdam.
6. Buffer Impacts (for DWR)
6a. Project is in which protect basin(s)?
Check all that apply.
Neuse Tar -Pamlico
Catawba Randleman
Goose Creek Jordan Lake
Other
16b. Impact Type
16c. Per or Temp ]F�.
Stream name 116e.
Buffer mitigation
16f. Zone 1 impact ]16g.
Zone 2 impact
�Allowable with Mitigation
F
ktrearn 1
1yes ���1245
179
6h. Total buffer impacts:
Zone I Zone 2
Total Temporary impacts: 0.00 0.00
Zone 1
Zone 2
Total Permanent impacts: 245.00
279.00
Zone I
Zone 2
Total combined buffer impacts: 245.00
279.00
61. Comments:
The impacts from the driveway are not a perpendicular crossing and falls under'Allowable with Mitigation Upon Authorization'. The DMS ILF Mitigation
Request Form is attached to mitigate for the 524 square feet of buffer impacts.
E. Impact Justification and Mitigation
1. Avoidance and Minimization
Ia. Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
The south access along Wilson's Mills Road was designed to provide the safest and most efficient traffic flow possible. The driveway on Wilson's Mills
Road is critical component to achieving this. Wilson's Mills Road is the primary thoroughfare through the Town and provides the traffic capacity
necessary for the project. Almost all traffic to the property will be using Wilson's Mills Road for ingress and egress. Main Street on the other hand is a
narrow, low volume road with steeper grades, and close to a railroad crossing, all of which presents safety concerns. Therefore, Wilson's Mills Road
provides the safest access option. The Main Street access will primarily serve tractor trailer deliveries, trash and vendor deliveries. When possible, we
always like to separate the passenger vehicle and truck vehicles for safety reasons. Based on these reasons, 2 access points are needed for safety and
efficiency.
In addition, the driveway on Wilson's Mills Road is required to be located in this location to provide the greatest separation distance from the intersection
This allows the road widening and new turn lane to be designed properly so that there are no safety conflicts with the existing intersection.
A retaining wall will be constructed at the edge of the southern access to reduce grading and minimize erosion in the vicinity of Stream 1. A cofferdam
will be utilized when working in the stream and the stream will be dewatered prior to in -stream construction. Construction shall be performed during low
flow conditions to minimize impacts to downstream water quality.
When working within wetlands, timber matting or a similar material will be utilized to minimize disturbance to the wetlands. Upon construction
completion, the material will be removed to allow the wetlands to return to natural conditions.
The proposed project has been planned and engineered to avoid aquatic resources to the greatest extent practicable. Where avoidance was not
feasible, proposed impacts were minimized during the siting, planning, and engineering phases of the project.
1b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
The development will be constructed via standard construction procedures. Appropriate construction techniques will be used, and erosion and sediment
control measures will be put in place prior to beginning construction activities, and will be implemented accordingly to minimize potential sedimentation
and other potential project -related impacts. Efforts will be made throughout the construction phases to minimize the extent and duration of project -related
disturbances to water resources.
2. Compensatory Mitigation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for impacts to Waters of the U.S. or Waters of the State?
Yes
No
2c. If yes, mitigation is required by (check all that apply):
DWR Corps
2d. If yes, which mitigation option(s) will be used for this project?
Mitigation bank Payment to in -lieu fee program Permittee Responsible Mitigation
4. Complete if Making a Payment to In -lieu Fee Program
4a. Approval letter from in -lieu fee program is attached
Yes No
4b. Stream mitigation requested:
(linear feet)
N/A
4d. Buffer mitigation requested (DWR only):
(square feet)
524
4f. Non -riparian wetland mitigation requested
N/A
4h. Comments
4c. If using stream mitigation, what is the stream temperature:
4e. Riparian wetland mitigation requested:
(acres)
N/A
4g. Coastal (tidal) wetland mitigation requested:
(acres)
N/A
6. Buffer mitigation (State Regulated Riparian Buffer Rules) - required by DWR
a
6a. Will the project result in an impact within a protected riparian buffer that requires buffer mitigation? If yes, you must fill out this entire form - please contact DWR for more information.
Yes No
6b. If yes, then identify the square feet of impact.
6c. Reason for impact
6d. Total impact (square
feet)
r 16e.
1�
Required mitigation
(square feet)
�Zone 1 JDriveway
�E5
t35
Zone 2 Driveway 279 1.5 419
6f. Total buffer mitigation required
1154
6g. If buffer mitigation is required, is payment to a mitigation bank or NC Division of Mitigation Services proposed?
Yes No
6j. Comments:
The impacts from the driveway are not a perpendicular crossing and falls under'Allowable with Mitigation Upon Authorization'. The DMS ILF Mitigation
Request Form is attached to mitigate for the 524 square feet of buffer impacts (1,154 with the multiplier).
F. Stormwater Management and Diffuse Flow Plan (required by DWR)
1. Diffuse Flow Plan
Ia. Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
Yes No
What type of SCM are you providing?
Level Spreader
Vegetated Conveyance (lower SHWT)
Wetland Swale (higher SHWT)
Other SCM that removes minimum 30% nitrogen
Proposed project will not create concentrated stormwater flow through the buffer
2. Stormwater Management Plan
2a. Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?*
Yes No
2b. Does this project meet the requirements for low density projects as defined in 15A NCAC 02H .1003(2)?
Yes No
2c. Does this project have a stormwater management plan (SMP) reviewed and approved under a state stormwater program or state -approved local government stormwater program?
Yes No
N/A - project disturbs < 1 acre
2d. Which of the following stormwater management program(s) apply:
Local Government State
Local Government Stormwater Programs
Phase 11 NSW USMP Water Supply
Please identify which local government stormwater program you are using.
Town of Wilson's Mills
Comments:
The stormwater management plan are currently being reviewed by the Town of Wilson's Mills. The stormwater details and plans are attached.
G. Supplementary Information
1. Environmental Documentation
Ia. Does the project involve an expenditure of public (federal/state/local) funds or the use of public (federal/state) land?
Yes No
2. Violations (DWR Requirement)
2a. Is the site in violation of DWR Water Quality Certification Rules (15A NCAC 2H .0500), Isolated Wetland Rules (15A NCAC 2H .1300), or DWR Surface WaterorWetland Standards or
Riparian Buffer Rules (15A NCAC 2B.0200)?*
Yes No
a
3. Cumulative Impacts (DWR Requirement)
3a. Will this project result in additional development, which could impact nearby downstream water quality? *
Yes No
3b. If you answered "no," provide a short narrative description.
This is a single and complete project. The project is not part of a larger planned development. No further impacts are anticipated beyond what is
included in this initial phase.
4. Sewage Disposal (DWR Requirement)
4a. Is sewage disposal required by DWR for this project?
Yes No NIA
4b. Describe, in detail, the treatment methods and dispositions (non -discharge or discharge) of wastewater generated from the proposed project. Ifthe wastewater will be treated at a
treatment plant, list the capacity available at that plant.
Waste water will be handled by Johnston County's Wastewater Treatment Plant.
5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or habitat?*
Yes No
5b. Have you checked with the USFWS concerning Endangered Species Act impacts?
Yes No
5c. If yes, indicate the USFWS Field Office you have contacted.
Raleigh
5d. Is another Federal agency involved?*
Yes No
5e. Is this a DOT project located within Division's 1-8?
Yes No
5f. Will you cut any trees in order to conduct the work in waters of the U.S.?
Yes No
5g. Does this project involve bridge maintenance or removal?
Yes No
5h. Does this project involve the construction/installation of a wind turbine(s)?*
Yes No
Unknown
5i. Does this project involve (1) blasting, and/or (2) other percussive activities that will be conducted by machines, such as jackhammers, mechanized pile drivers, etc.?
Yes No
5j. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
FaC and consultation with the USFWS and NCNHP. A Request for Information/Concurrence was submitted to USFWS on February 13, 2024, but a
response has not yet been received; the concurrence letter will be submitted at a later date upon receipt. The Request for Information/Concurrence letter
is included in the supporting documents attachment.
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as an Essential Fish Habitat?*
Yes No
6b. What data sources did you use to determine whether your site would impact an Essential Fish Habitat?
NOAA Essential Fish Habitat Mapper
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 status?
Yes No
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
NCHPO database and consultation with the SHPO. Based on the response from SHPO (ER-24-0325), the agency conducted a review of the project and
are aware of no historic resources which would be affected by the project. The SHPO concurrence letter is included in the supporting documents
attachment.
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 1 00-year floodplain?
Yes No
8c. What source(s) did you use to make the floodplain determination?*
FEMA FIRM Floodplain Mapper. FIRM Panel No. 3720169600K, effective 6/20/2018.
Miscellaneous
IS
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review. Documents should be combined into one file when
possible, with a Cover Letter, Table of Contents, and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach document
DGMarket SupportingDocuments-merged.pdf 72.32MB
DGMARK-1.PDF 235.93KB
File must be PDF or KMZ
Comments
Signature
By checking the box and signing below, I certify that:
The project proponent hereby certifies that all information contained herein is true, accurate, and complete to the best of my knowledge and belief'; and
The project proponent hereby requests that the certifying authority review and take action on this CWA 401 certification request within the applicable reasonable period of time.
I have given true, accurate, and complete information on this form;
I agree that submission of this PCN 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");
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature; AND
I intend to electronically sign and submit the PCN form.
Full Name:
Timothy O'Halloran
Signature
7-1A-0 MY 0 ffALLO�Ad
Date
4/12/2024
8