20170450 Ver 2_Re-Issuance_Renewal Request_20211025

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NORTH CARO.INA
Staff Review Form
Envlmnm¢ntrtl Qvofiry
Updated September2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID#* Version* 2
20170450
Is this project a public transportation project?* Yes
No
Is this a DOT Yes No
project?*
Reviewer List:* Robert Patterson:eads\rdpatterson
Select Reviewing Office:* Mooresville Regional Office-[phone]
Does this project require a request for payment to be sent?*
Yes
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:* 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: Jeffrey L.Wyatt
Who is submitting the information?
Email Address: [e-mail]
Project Information
Existing ID#: Existing Version:
20170450 1
20170001(no dashes) 1
Project Name: Bridge 176 on SR 1875
Is this a public transportation project?
Yes
No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
TIP#: WBS#:
17BP.12.R.60
(Applies to DOT projects only)
County(ies)
Gaston
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
Only pdf or kmz files are accepted.

Describe the attachments or
comments:
This was issued as a GC 4085 and has since expired. NCDOT is requesting a reissuance under GC 4132 that
replaced the GC 4085.
Sign and Submit
..............................................................................................................................................................................................................................................................................................................................................................
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: r� r
Cl PMz-
Submittal Date: Is filled in automatically.