20211107 Ver 1_401 Application_20211008

Staff Review Form •
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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* 1
20211107
Is this project a public transportation project?* (' Yes
r No
Is this a DOT ( Yes C No
project?*
Reviewer List:* Hannah Sprinkle:eads\hhsprinkle
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
✓ Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
✓ Pre-Application Submittal
✓ Re-Issuance\Renewal Request
r Stream or Buffer Appeal
Pre-Filing Meeting Information
Before submitting this form please ensure you have submitted the Pre-Filing Meeting Request Form as we will not
be able to accept your application without this important first step.The Pre-Filing Meeting Request Form is used in
accordance with 40 C.F.R. Section 121.4(a)"At least 30 days prior to submitting a certification request,the project
proponent shall request a pre-filing meeting with the certifying agency"and in accordance with 40 C.F.R. Section
121.5(b)(7),and (c)(5)all certification requests shall include documentation that a pre-filing meeting request was
submitted to the certifying authority at least 30 days prior to submitting the certification request.Click here to read
more information on when this form is needed prior to application submission or here to view the form.
Attach documentation of Pre-Filing Meeting Request here:
20211107 Ver 1_Meeting Request Review 20210711.pdf 655.17KB
Date for Meeting Request 7/21/2021
ID# 20211107 Version 1
Project Contact Information
Name: Kristi Lynn Carpenter for Jennifer Harrod
Who is submitting the inforrration?
Email Address: [e-mail]
Project Information
Existing ID#: Existing Version:
20211107 1
20170001(no dashes) 1
Project Name: Widen 1-95(I-5987AB)
Is this a public transportation project?
a Yes
✓ No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
✓ Yes r No r Unknown

TIP#: WBS#:
I-5987AB 47533.1.1
(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
Final BINDER I-
5987_IP_Application_20211007(NCDOT 98.14MB
Signature).pdf
Only pdf or krre files are accepted.
Describe the attachments
or comments:
Original submission to Hannah Sprinkle via email.
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.