20201785 Ver 1_401 Application_20201120

Staff Review Form •
NORFH CA.,i0:INA
En vironmenfrr!QvoGry
Updated September 4,2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
6* Yes r No
ID#* Version* 11
20201785
Is this project a public transportation project?* (' Yes
r No
Is this a DOT ( Yes C No
project?*
Reviewer List:* Joanne Steenhuis:eads\jhsteenhuis
Select Reviewing Office:* Wilmington Regional Office-[phone]
Does this project require a request for payment to be sent?*
Yes
r
No

Project Submittal Form
Please note:fields marked with a red asterisk *below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type:* r For the Record Only(Courtesy Copy)
r New Project
r Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
r Pre-Application Submittal
✓ Re-Issuance\Renewal Request
✓ Stream or Buffer Appeal
Project Contact Information
Name: NCDOT Division 6
Who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Project Name: Replace Bridge No.770239 on SR 1515 over Burnt Swamp
Is this a public transportation project?
r Yes
✓ No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
✓ Yes r No r Unknown
TIP#: WBS#:
17BP.6.PE.76
(Applies to DOT projects only)
County(ies)
Robeson
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
17BP.6.R.76_Permit Drawings.pdf 818.26KB
Only pa or krrz files are accepted.
Describe the attachments
or comments:
The project WBS number just recently changed from 17BP.6.R.76 to 17BP.6.PE.76. Lat/Long Coordinates
are 34.718611,-79.127058.
Project is for non-reporting NWP#3 and GC 4132.
Sign and Submit
.......................................................................................................................................................................................................................................................................................................................................................................................................
17 By checking the box and signing box below, I certify that:

■ I,the project proponent, hereby certifies that all information contained herein is true,accurate, and complete to
the best of my knowledge and belief.
■ I,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 agree that submission of this online 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 online form.
Signature:
Submittal Date: Is filled in autocratically.