20201086 Ver 2_Modification Request_20210309

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* 2
20201086
Is this project a public transportation project?* (' Yes
r No
Is this a DOT ( Yes C No
project?*
Reviewer List:* Rob Ridings:eads\rgridings
Select Reviewing Office:* Central 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)
✓ New Project
✓ Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
✓ Pre-Application Submittal
✓ Re-Issuance\Renewal Request
✓ Stream or Buffer Appeal
Pre-Filing Meeting Information
Pre-Filing meeting request information is not needed for this project.
Project Contact Information
.......................................................................................................................................................................................................................................................................................................................................................................................................
Name: Chad Coggins
Who is submitting the information?
Email Address: [e-mail]
Project Information
............................................................................................................................................................................................................................................................................................................
Existing ID#: Existing Version:
20201086 1
20170001(no dashes) 1
Project Name: ROCKY MOUNT- 1-95 AT SR 1770(SUNSET AVENUE).(COMB W/R-5720)
Is this a public transportation project?
a Yes
r No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
a Yes r No r Unknown
TIP#: WBS#:
u-5026 44033.3.3
(Applies to DOT projects only)
County(ies)
Nash
Please upload all files that need to be submited.
Oick the upload button or drag and drop files here to attach docurrent
U-5026_R-5720_Permit_Modification.pdf 6.44MB
Only pdf or Ivre files are accepted.
Describe the attachments
or comments:

permit mod request
Sign and Submit
.......................................................................................................................................................................................................................................................................................................................................................................................................
fJ 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 automatically.