20021618 Ver 1_COMPLETE FILE_20021008

O? ?ArF9 Michael F. Easley
OCR QG Governor
Uj William G. Ross, Jr., Secretary
Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
December 4, 2002
DWQ Project No. 02-1618
County: Edgecombe
Page 1 of 2
Rocky Mount Public Housing Authority
P.O. Box 4717
Rocky Mount, NC 27803-0717
Subject Property: Whatley Cove (Springfield Housing S/D), SR 1250, Rocky Mount, NC
UT to Gay Branch [03-03-02, 28-(72.5), C NSW]
APPROVAL of 401 Water Quality Certification and AUTHORIZATION CERTIFICATE per the Tar-Pamlico River
Buffer Protection Rules (15A NCAC 213.0259) with ADDITIONAL CONDITIONS
To Whom It May Concern:
You have our approval, in accordance with the attached conditions and those listed below, to place fill within or.
otherwise impact 75 feet of stream and approximately 7,500 square feet (ft) of protected riparian buffers for the
purpose of constructing a road crossing at the subject property, as described within your application dated September
23, 2002 (received on October 8, 2002). After reviewing your application, we have decided that the impacts are
covered by the N.C. Division of Water. Quality (DWQ) General Water Quality Certification Number(s) 3362. The
Certification(s) allows you to use Nationwide Permit 39 when issued by the US Army Corps of Engineers (USACE).
This letter shall also act as your approved Authorization Certificate for impacts to the protected riparian buffers per 15A
NCAC 2B .0259. In addition, you should obtain or otherwise comply with any other required federal, state or local
permits before you go ahead with your project including (but not limited to) Erosion and Sediment Control and Non-
discharge. Also, this approval will expire when the accompanying 404 permit expires unless otherwise specified in the
General Certification.
This approval is only valid for the purpose and design that you described in your application and including any
modifications listed below. If you change your project, you must notify us and you may be required to send us a new
application. If the property is sold, the new owner must be given a copy of this Certification and approval letter and is
thereby responsible for complying with all conditions. If total fills for this project (now or in the future) exceed one acre
of wetland or 150 linear feet of stream, compensatory mitigation may be required as described in 15A NCAC 2H .0506
(h). For this approval to be valid, you must follow the conditions listed in the attached certification and any additional
conditions listed below.
Conditions:
1. Diffuse Flow
An additional condition is that all stormwater shall be directed as diffuse flow at non-erosive velocities prior to
entering and through the protected stream buffers and will not re-concentrate before discharging into the stream as
identified within 15A NCAC 2B .0259(5). This may require the use of "level spreaders" at some of the stormwater
discharge locations. You may wish to review the DWQ "Draft Level Spreader Design Options" document to ensure
that you are providing diffuse flow. This document can be downloaded from our web site at
http://h2o.enr.state.nc.us/ncwetiands/level.pdf or we can mail you a copy by calling [phone]. Please note
that no new stormwater conveyances (e.g., road ditches, pipes, etc.) are allowed within and through the protected
buffers. If you have any questions regarding this condition you may call Mr. Todd St. John, P.E. of the
Wetlands/401 Unit at [phone].
North Carolina Division of Water Quality, WETLANDS / 401 UNIT
2321 Crabtree Blvd., Raleigh, NC 27604-2260 (Location)
1650 Mail Service Center, Raleigh, NC 27699-1650 (Mailing Address)
919-733-1786 (phone), 919-733-6893 (fax), http://h2o.enr.state.nc.us/ncwetlands
Page 2 of 2
2. Certificate of Completion
Upon completion of all work approved within the 401 Water Quality Certification or applicable Buffer Rules, and any
subsequent modifications, the applicant is required to return the attached certificate of completion to the
401/Wetlands Unit, North Carolina Division of Water Quality, 1650 Mail Service Center, Raleigh, NC, 27699-1650.
3. Deed Notifications
Deed notifications or similar mechanisms shall be placed on all retained jurisdictional wetlands, waters and
protective buffers in order to assure compliance for future wetland, water and buffer impact. These mechanisms
shall be put in place prior to impacting any wetlands, waters and/or buffers approved for impact under this
Certification Approval and Authorization Certificate.
If you do not accept any of the conditions of this Certification (associated with the approved wetland or stream impacts),
you may ask for an adjudicatory hearing. You must act within 60 days of the date that. you receive this letter. To ask for
a hearing, send a written petition, which conforms to Chapter 150B of the North Carolina General Statutes to the Office
of Administrative Hearings, P.O. Box 27447, Raleigh; N.C. 27611-7447. This certification and its conditions are final
and binding unless you ask for a hearing.
Any disputes over determinations regarding this Authorization Certificate (associated with the approved buffer impacts)
shall be referred in writing to the Director for a decision. The Director's decision is subject to review as provided in
Articles 3 and 4 of G.S. 150B.
This letter completes the review of the Division of Water Quality under Section 401 of the Clean Water Act and the Tar-
Pamlico riparian buffer protection rule as described within 15A NCAC 2B .0259. If you have any questions, please
telephone John Dorney at 919-733-9646 or Bob Zarzecki at 919-733-9726.
Sincerely,
Klimek, P.E.,
'Q, Director
Attachments: Certificate of Completion
Sample Deed Notification
GC 3362
Cc: George Williams, The G.H. Williams Collaborative, 411 W. Chapel Hill St., Suite 1103, Durham, NC 27701
USACE Raleigh Regulatory Field Office
DWQ Raleigh Regional Office
File Copy
Central Files
DWQ # 021618
December 4, 2002
bz
MEMORANDUM
TO: John Dorney Regional Contact: Steve Mitchell
Non-Discharge Branch WO Supervisor:
Date:
SUBJECT: WETLAND STAFF REPORT AND RECOMMENDATIONS
Facility Name Springfield Housing S/D Wbatley Cove County Edgecombe
Project Number 02 1618 County2
Recvd From APP Region Raleigh
Received Date 10/8/02 Recvd By Region
Project Type residential S/D
Certificates Stream Stream Impacts (ft.)
Permit Wetland Wetland Wetland Stream Class Acres Feet
Type Type Impact Score Index Prim. Supp. Basin Req. Req. ka In
TPBR Buffers O Y O N F_F28-(66.5) WSIV Ns 30,302. 0.11 F F-- F-
?- O ti' -*N
F- F- F-F_F_ 0.01 F_ F___`T__
r
Mitigation Wetland
MitigationType Type Acres Feet
Is Wetland Rating Sheet Attached? Q Y O N Did you request more info? Q Y Q N
Have Project Changes/Conditions Been Discussed With Applicant? Q Y Q N
Is Mitigation required? Q Y O N Recommendation: Q Issue O Issue/Cond O Deny
cc: Regional Office
Central Office Page Number 1
Provided by Region: Latitude (ddmmss) Longitude (ddmmss)
Triage Check List
Date: Project Name:
To: ? ARO Mike Parker
? FRO Ken Averitte
? MRO Mike Parker
RRO Steve Mitchell
Ol

From: ,
z ..
7 /-D

County: 4E?54r_
? WaRO Deborah Sawyer
? WiRO Joanne Steenhuis
? WSRO Jennifer Frye
Telephone : (919) T
The file attached is being forwarded to your for your evaluation.
Please call if you need assistance.
? Stream length impacted
? Stream determination
? Wetland determination and distance to blue-line surface waters on USFW topo maps
? Minimization/avoidance issues
? Buffer Rules (Meuse, Tar-Pamlico, Catawba, Randleman)
? Pond fill
? Mitigation Ratios
? Ditching
? Are the stream and or wetland mitigation sites available and viable?
? Check drawings for accuracy .
? Is the application consistent with pre-application meetings?
? Cumulative impact concern

Comments: A-i-e _ 7 , _ 'r ,r,,, , ,? 4l s ? 5 r?
Office Use Only:
U
1.
II.
G Action ID No. ?,....,.......?.?.,..?.?...?. DWQ N
(ruiny particular item is not applicable to this project, please enter "
Processing
° Uf 8
P ?FF
Tio Version May 2002
1. Check all of the approval(s) requested for this project:
? Section 404 Permit 117
Riparian or Watershed Buffer Rules
Lend
? Section 10 Permit Isolated Wetland Permit from DWQ
? 401 Water Quality Certification
2. Nationwide, Regional or General Permit Number(s) Requested: G E N P-FAQ
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ?
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (verify availability with NCWRP prior to submittal of PCN), complete
section VIII and check here: ? N Its
5. If your project is located in any of North Carolina's twenty coastal counties (listed on page
4), and the project is within a North Carolina Division of Coastal Management Area of
Environmental Concern (see the top of page 2 for further details), check here: ? N A
Applicant Information
1. Owner/Applicant Information
Name: 1 e_y MbuNr Pu64-1C 40oS!N6 Au7-140i°iry
Mailing Address: B0. Box 4717
0-717
Telephone Number: q0T IqqO Fax Number: Z5Z- 1407- 1957-
E-mail Address: L I? ,R Y (?2 K M -- N /a o n RLG
2. Agent/Consultant Information (A signed and dated copy of the Agent Authorization letter
must be attached if the Agent has signatory authority for the owner/applicant.)
Company Affiliation:
Mailing Address:
AS (-U /LL/ NM-5
S- 1 103
btu-14pal 1- NC 27701
Telephone Number: -.I I c(- `I Sao - 7162G _ Fax Number: TI 7 - (oBR - 4 4 9 Z
E-mail Address: G t4 w C? A^ (F 1#--
,p (J 1V (=, o ryl
Page 5 of 12
III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
bo n arie and dev 1o m nt plan in r lation to surraundintx nropertiea. Roth the vicinity map
ttric`i' s`?te plan must fncqun?e a scape in anl r north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries. outlined. Plan drawings, or other maps may be included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 1 I by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: (.U [f A I _F 4 CO C S ?PiiU6r1 EI,D 14oU s /NC, 5ugDt(/i_90A)
2. T.I.P. Project Number or State Project Number (NCDOT Only): N A
3. Property Identification Number (Tax PIN): 'OB 12 SCE PG Z07
4. Location
County: E0(.E Com 6E Nearest Town: ?-Dc-y- MDcv,,-)T
Subdivision name (include phase/lot number): to v£
Directions to site (include road numbers, landmarks, etc.): AJ F
la r a A &m S ?. 12 SCE N o R 7-H O P6ceT(
C.I (,!1T 5iof-.: n r QoAb
5. Site coordinates, if available (UTM or Lat/Long): ?/ N
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Property size (acres):
7. Nearest body of water (stream/river/sound/ocean/lake):
W
8. River Basin: A 2 - PAS')
(Note - this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at littp:Hii2o.enr.state.nc tis/admin/maw/.)
9. Describe the existing conditions on the site and general land use in the vicinity of the project
at the time of this application: 5 Gi .u 8 TP2,E6 - g bzrAc.r,iT" ALF A
1<? ( (0M/Y F2C1A%,, A&)1) R_C7_,;10EA)TIAt.

Page 6 of 12
10. Describe the overall project in detail, including the type of equipment to be used: 70 C20SS
PFSt
11. Explain the purpose of the proposed work: . hu R Pose J -s TO C P- 9- ATg A
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies; of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
NO FLITU2E 7'1`P-M ITS R-Ea (f 2i-,O
VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
Page 7 of 12
Provide a written description of the proposed impacts: SM P ACT 5-0 F007
R PAM t a u FFG_e t= a c &l S r n Ir P, C STt? c o M /_1 w? r, -1-* 1- EL,
2. Individually list wetland impacts below:
Wetland Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***
F?t,c 0101 N 1A&)lJ15L
Dell C1
- -

# T .?.t o ..T.
°• CUM ttttt/ UL Sepatttuty tutu tuerutry temporary impacts. impacts include, but are not liTtlited to: mechanized clearing, grading, fill,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year tloodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps.' Maps are available through the FE MA Map Service Center at 1-800-358-9616, or
online at http://www.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina nay, bog, etc.) Indicate if wetland is isolated (determination of isolation to be made by USACE only).
List the total acreage (estimated) of all existing wetlands on the property: O, O 7 AC,
Total area of wetland impact proposed: C. 01
3. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Site Number
(indicate on map)
Type of Impact* Length of
Impact
(linear feet)
Stream Name** Average Width
of Stream
Before Impact Perennial or
Intermittent?
(please secif )
A A S

S r. J7? ? r ?S

. IZL M,tt ttultut;t scpatatety ant taenttry temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net losstgain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.uses.eov. Several internet sites also allow direct download and printing of USGS maps (e.g., www.towzone.com,
www.ntap(luest.cont, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: N p?
Page 8 of 12
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic
Ocean and any other water of the U.S.) below:
Open Water Impact
site Number

(indicate on ma)

Type of rnrt+aut Area of

tmtawot
(acres)
Name of Waterbody

(if applicable) Type of Waterbody

(take, pond, estuary, sound,
bay, ocean, etc.)

* t;et n6 ... i. _., .,_ ?c.
--• - ?-?•• . 11 ?. t ..•". y a„u ,ucfiu„y lcmpurary impacts. impacts mciude, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
5. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be
included above in the wetland and stream impact sections. Also, the proposed pond should
be described here and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ? uplands ? stream ? wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of
draw-down valve or spillway, etc.):
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond,
local stormwater requirement, etc.): "i _I _"
Size of watershed draining to pond: Expected pond surface area:
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It may be useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
PE Ct"IS aou F_ i s A,u 1 ijT-g6-e0c Aer OF T'iL4 E I U 80 C POCG-<iA16
A 1S ttnt? I'rfr S NFr?l?. NI0r? LOAq /S 7-4fr QAJCY W A4 THAT / #t" ir';?rs1F6-1 S
CQn) A(-cr=s- -t-uIr 8(A l(-DtAIr 714r- .5mAU'L9sr aeruE w ?onl toAs u sEoa
To s AT i s F Y --l E t o CAc A u ri to i 7" Y
VIII. Mitigation
DWQ In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
Page 9 of 12
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
ON-100*10 rw60orae will be Oottsldered in determining acceptability or appropriate and practicable
mitigation as proposed. Examples of mitigation that may be appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
littp:Hli2o.enr. state. nc.us/newetiands/strmgide.htmi.
Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP). Please note it is the applicant's responsibility to contact the NCWRP at
[phone] to determine availability and to request written approval of mitigation prior
to submittal of a PCN. For additional information regarding the application process for the
NCWRP, check the NCWRP website at http://h2o.enr.state.nc.us/wrphndex.litm. If use of
the NCWRP is proposed, please check the appropriate box on page three and provide the
following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet): A1.1 A
Amount of Riparian wetland mitigation requested (acres):
Amount of Non-riparian wetland mitigation requested (acres): A IN
Amount of Coastal wetland mitigation requested (acres):
Page 10 of 12
IX. Environmental Documentation (required by DWQ)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes " No ?
If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ? No M
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ? No ? NIA
X. Proposed Impacts on Riparian and Watershed Buffers (required by DWQ)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 Randleman Rules and
Water Supply Buffer Requirements), or other (please identify TA K - 1A m )?
Yes M No ? If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(square feet) Multiplier Required
Mitigation

2 2000 1.5 30oo
Total IZ, 000
Lone i extends out 30 feet perpendicular from near hank of channel; Zone 2 extends an
additional 20 feet from the edge of Zone I.
Page 11 of 12
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration / Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or.0260.
XI. Stormwater (required by DWQ)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
Ey r5rW6 imPF2ulous - 5% j'2dPosr A - 1(a?7e ALL S-MLOM UJATF-A- WILL
Su E Cr F-'LOW THfi OU 41.1 "Ae Flu F Fe t Ar? l-A 13 ,J T-Fil rttJG TId E
LPP,10A6C W AY
XII. Sewage Disposal (required by DWQ)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
0 try r, z Roc r- /YJbuN T W rL-c 45P7- 714 6 5EW rt-OUJ -
S M7"i? PgR.M r r- 14 A-5 8 F? / S S u ?,D
XIII. Violations (required by DWQ)
Is this site in violation of DWQ Wetland Rules (15A NCAC 211.0500) or any Buffer Rules?
Yes ? No K
Is this an after-the-fact permit application?
Yes ? No 9
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibilitX problems, or other issues outside of the applicant's control).

Applica M
(Agent's sig ure is
s Signat
Date
if an authorization letter from the applicant is provided.)
Page 12 of 12
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