20150928 Ver 1_STR - YD 101 Cold - Surry_20160609

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatorv Miti�ation Responsibilitv Transfer Form
Permittee: NCDOT/ Attn: Heath Slaughter Action ID: SAW-2015-02479
Project Name: NCDOT/SR1600/Bridge298/176P.11.R.82/Divii County: Surry
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 Division of Mitigation Services (NCDMS), who will then sign the form to verify the
transfer of the mitigation 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 mitigation 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/or HUC must be provided to the appropriate mitigation Sponsors.
Instructions to Sponsor: The Sponsor must verify that the mitigation requirements (credits) shown below are available at
the identified site. By signing below, the Sponsor is accepting full responsibility for the identified mitigation, regardless of
whether or not they have received payment from the Permittee. Once the form is signed, the Sponsor must update the
bank ledger and provide a copy of the signed form and the updated bank ledger to the Permittee, the USACE Project
Manager, and the Wilmington District Mitigation Office (see contact information on page 2). 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-di�it HUC and Basin:
Stream Impacts (linearfe
Warm Cool
Wetland
Yadkin River Basin
cts (acresl
Cold � Riparian Riverine � Riparian Non-Riverine � Non-Riparian � Coastal
36
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
Compensatory Mitigation F
Stream Mitigation
Warm Cool
uirements: 8-digit HUC and Basin: 03040101, Yadkin River Basin
Wetland Mitigation (credits)
Cold Riparian Riverine Riparian Non-Riverine Non-Riparian Coastal
72
Mitigation Site Debited: NCDMS
(List the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDMS. If the
NCDMS acceptance letter identifies a specific site, also list the specific site to be debited).
Section to be tompleted by the Mitigation Sponsor
Statement of Mitigation Liability Acceptance: I, the undersigned, verify that I am authorized to approve mitigation
transactions for the Mitigation Sponsor shown below, and I 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 (and/or advance credits for NCDMS), 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 Name: ��1�1,.JGC_� 1� 1' /S
Name of Sponsor's Authorized Representative: �-�`Y !`1'i . U'/}�ISii
Signature of Sponsor's Authorized Representative f Date c�f Signature
Page 1 of 2 Form Updated 12 September, 2014

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 receipt 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 Sponsor, 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 30 days of
permit issuance. NCDOT remains fully responsible for the mitigation until the USACE has received this form, confirming
that the Sponsor has accepted responsibility for providing the mitigation requirements listed herein.
� Signed copies of this document must be retained by the Permittee, Mitigation Sponsor, and in the USACE
administrative records for both the permit and the Bank/ILF Instrument. It is the Permittee's responsibility to ensure
that the USACE Project Manager (address below) 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 North 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 Bank/ILF Instrument.
Comments/Additional Conditions:
This form is not valid unless signed below by the USACE Project Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsor should provide copies of this form along with an updated bank ledger to: 1J the Permittee, 2J the
USACE Project Manager at the address be%w, and 3J ti►e Wilmington Distritt Mitigation Ofjice, Attn: Todd Tugwell,
11405 Falls of Neuse Road, Wake Forest, NC 27587 (email: [e-mail]. Questions regarding this form
or any of the permit conditions may be directed to the USACE Project Manager below.
USACE Project Manager:
USACE Field Office:
Steve Kichefski
Asheville Regulatory Field Office
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
Email: [e-mail]
KICHEFSKI.STEVEN.�.� DigitallysignedbyKICHEFSKI.STEVEN.L.1386908539
DN: c=US, a=U.S. Government, ou=DoD, ou=PKl,
386908539 ou=USA, cn=KICHEFSKI.STEVEN.L.1386908539
Date: 2016.D6.03 00:08:25 -04'00'
USACE Project Manager Signature
June 2 2016
Date of Signature
Current Wilmington District mitigation guidance, including information on mitigation ratios, functional 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
The Wilmington District is committed to providing the highest level of support to the public. To help us ensure we continue to do so, please complete the
Customer Satisfaction Survey located at our website at htta://re�ulatorv.usaeesurvev com/ to complete the survey online.