20211334 Ver 1_ePCN Application_20211130

DW R
Divi.ha of ware.Resources
Pre-Construction Notification (PCN) Form
For Nationwide Permits and Regional General Permits
(along with corresponding Water Quality Certifications)
June 1,2021 Ver 4.1
Initial Review
Has this project met the requirements for acceptance in to the review process?*
Yes
No
Is this project a public transportation project?*
Yes No
Change only if needed.
BIMS#Assigned* Version#*
20211334 1
Is a payment required for this project?*
No payment required What amout is owed?*
Fee received $240.00
Fee needed-send electronic notification $570.00
Reviewing Office* Select Project Reviewer*
Central Office-[phone] Rob Ridings:eads\rgridings
Information for Initial Review
1a.Name of project:
Intersection Improvements at SR 2320 and Shepard School Road
la.Who is the Primary Contact?*
Chris Ray
1 b.Primary Contact Email:* 1c.Primary Contact Phone:*
[e-mail] [phone]
Date Submitted
11/30/2021
Nearest Body of Water
Beaverdam Creek
Basin
Neuse
Water Classification
QNSW
Site Coordinates
Latitude: Longitude:
35.838580 -78.314786
A. Processing Information
County(or Counties)where the project is located:
Wake
Is this a NCDMS Project
Yes No
Is this project a public transportation project?*
Yes No
Is this a NCDOT Project?*
Yes No
Pre-Filing Meeting Information

Is this a courtesy copy notification?*
Yes No
ID# Version
20211334 1
Pre-fling Meeting or Request Date
9/8/2021
Attach documentation of Pre-Filing Meeting Request here:
Click the upload button or drag and drop files here to attach document
File type must be PDF
1a.Type(s)of approval sought from the Corps:
Section 404 Permit(wetlands,streams and waters,Clean Water Act)
Section 10 Permit(navigable waters,tidal waters,Rivers and Harbors Act)
Has this PCN previously been submitted?*
Yes
No
1 b.What type(s)of permit(s)do you wish to seek authorization?
Nationwide Permit(NWP)
Regional General Permit(RGP)
Standard(IP)
1c.Has the NWP or GP number been verified by the Corps?
Yes No
Nationwide Permit(NWP)Number: 14-Linear transportation
NWP Numbers(for multiple NWPS):
1d.Type(s)of approval sought from the DWR:
401 Water Quality Certification-Regular 401 Water Quality Certification-Express
Non-404 Jurisdictional General Permit Riparian Buffer Authorization
Individual 401 Water Quality Certification
le.Is this notification solely for the record because written approval is not required?
For the record only for DWR 401 Certification: Yes No
For the record only for Corps Permit: Yes No
1f.Is this an after-the-fact permit application?"
Yes No
1g.Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
Yes No
1g.Is payment into a mitigation bank or in-lieu fee program proposed for mitigation of impacts?
Yes No
1 It.Is the project located in any of NC's twenty coastal counties?
Yes No
1j.Is the project located in a designated trout watershed?
Yes No
B. Applicant Information
1d.Who is applying for the permit?
Owner Applicant(other than owner)
le.Is there an Agent/Consultant for this project?"
Yes No
2.Owner Information
2a.Name(s)on recorded deed:
The Town of Zebulon intends to acquire right-of-way prior to construction.A table listing current
property owners is included in Appendix C.
2b.Deed book and page no.:

2c.Contact Person:
Chris Ray
2d.Address
Street Address
450 East Horton Street
Address Line 2
City State/Province/Region
Zebulon NC
Postal/Zip Code Country
27597 USA
2e.Telephone Number: 2f.Fax Number:
[phone]
2g.Email Address:*
[e-mail]
3.Applicant Information(if different from owner)
3a.Name:
Chris Ray
3b.Business Name:
Town of Zebulon
3c.Address
Street Address
450 East Horton Street
Address Line 2
City State/Province/Region
Zebulon NC
Postal/Zip Code Country
27597 USA
3d.Telephone Number: 3e.Fax Number:
[phone]
3f.Email Address:
[e-mail]
4.Agent/Consultant(if applicable)
4a.Name:
Amanda Johnson
4b.Business Name:
WSP USA
4c.Address
Street Address
434 Fayetteville Street
Address Line 2
Suite 1500
City Stale/Province/Region
Raleigh NC
Postal/Zip Code Country
27601 USA
4d.Telephone Number: 4e.Fax Number:
[phone]
4f.Email Address:*
[e-mail]
C. Project Information and Prior Project History
1.Project Information
1b.Subdivision name:
(if appropriate)
1c.Nearest municipality/town:
Zebulon,NC

2.Project Identification
2a.Property Identification Number:
2706303537,2706300773,2706206369,
2706219033,2706209765,2706217463, 2b.Property size:
2706313724,2706213256,2763044997 8.4
2c.Project Address
Street Address
Shepard School Rd,Proctor St,Old Bunn Rd
Address Line 2
City State/Province/Region
Zebulon NC
Postal/Zip Code Country
27597 USA
3. Surface Waters
3a.Name of the nearest body of water to proposed project:
Beaverdam Creek
3b.Water Resources Classification of nearest receiving water:*
C;NSW
3c. What river basin(s)is your project located in?*
Neuse
3d.Please provide the 12-digit HUC in which the project is located.
030202030101
4. Project Description and History
4a.Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this application:
The proposed Intersection Improvements at SR 2320(Proctor Street&Old Bunn Road)and Shepard School Road project limits extend approximately 0.17 mile along Shepard School
Road and 0.22 mile along SR 2320.The project area is approximately 8.4 acres in size.A majority of the project area along the existing roadway is developed,including areas of open
space and low-density development.There are also areas of cultivated cropland,forest,and maintained grass/forb outside of the existing roadway.There are three places where the
project crosses a delineated jurisdictional stream.There are three wetlands that were delineated within the project area.
4b.Have Corps permits or DWR certifications been obtained for this project(including all prior phases)in the past?*
Yes No Unknown
4f.List the total estimated acreage of all existing wetlands on the property:
0.31
4g.List the total estimated linear feet of all existing streams on the property:
443
4h.Explain the purpose of the proposed project:
The Town of Zebulon is seeking to improve vehicular and pedestrian safety at the SR 2320(Old Bunn Road/Proctor Street)and Shepard School Road intersection by adding turn lanes,
sidewalks,and pedestrian and traffic signals.The newly installed signals will increase safety at the intersection.There has been a total of 15 crashes at the intersection from 2015 to 2019;
a fatal crash occurred at the intersection in 2019.To accommodate the sidewalks and additional lanes,drainage improvements are also being proposed.

4i.Describe the overall project in detail,including indirect impacts and the type of equipment to be used:*
Shepard School Road(-L-)is proposed to be widened from two lanes to four lanes.The four lanes will include a median lane with turning lanes on each side,and a single lane traveling in
the opposite direction.Curb and gutter will be installed on both sides of the road.Catch basins are proposed along the curb and gutter and will tie into an existing 30"reinforced concrete
pipe(RCP)-III near Station 14+40.On the other side of the road,the 30"RCP will be collared and extended to the proposed roadway fill slope to accommodate the road widening.
SR 2320(-Y-)is also proposed to be widened from two lanes to four lanes.The four lanes will include a median lane with turning lanes on each side,and a single lane traveling in the
opposite direction.A proposed 48"RCP-III cross pipe will replace the existing 30"RCP.The new 48"RCP-III will be longer than the existing 30"RCP to accommodate the road widening.
Curb and gutter will be installed on both sides of the road.North of the intersection,drainage transitions from curb and gutter to an open shoulder/ditch section.
The project also includes new 5'sidewalks along Shepard School Road and SR 2320.South and east of the intersection,the existing 4'sidewalk will be removed due to road widening.A
new 5'sidewalk will be installed along the road where it will be widened and tie to the existing sidewalk outside of the project.
The intersection improvements will result in unavoidable impacts to jurisdictional Waters of the U.S.,as described below.
Shepard School Road:On the east side of the road at Impact Site W1,temporary fill impacts to Wetland WC will be necessary to allow equipment access for roadway construction.No
permanent wetland impacts are proposed at this location.At Impact Site S3,on the west side of the road,permanent stream impacts(fill)to Stream SA will result from the proposed 30"
RCP extension that will be required for the road widening.Bank stabilization proposed at the outlet of the extended culvert will result in permanent stream impacts along Stream SA.At
Site S4,north of the intersection,a jurisdictional roadside ditch that runs parallel to Shepard School Road north of the intersection is proposed to be filled to accommodate the road
widening.
SR 2320:At Impact Site S1,bank stabilization is proposed at the outlet of a proposed lateral'v'ditch that will run parallel to the widened road and will result in permanent stream impacts
to Stream SB.Also,the existing 30"RCP will be replaced by a new 48"RCP and extended.Permanent stream impacts to Stream SB will result from the proposed culvert extension(fill)
and bank stabilization at the inlet in this location.At Impact Site S2,on the opposite side of the road from Site S1,permanent stream impacts to Stream SB will result from the proposed
48"RCP that will replace and extend past the existing 30"RCP(fill)and bank stabilization at the outlet in this location.
There will be impacts to Neuse River riparian buffers along Streams SA and SB.At Impact Sites B2,B3,B4,B5,and a section of B1,riparian buffer impacts are due to roadway
construction activities at perpendicular stream crossings.At the remaining section of B1,there will be impacts to the riparian buffer where the stream runs parallel to SR 2320.
Equipment used to construct the project may include but are not limited to bulldozers,backhoes,tracked excavators,paving equipment,and graders.
5. Jurisdictional Determinations
5a.Have the wetlands or streams been delineated on the property or proposed impact areas?*
Yes No Unknown
Comments:
A Preliminary Jurisdictional Determination(PJD)and Approved Jurisdictional Determination(AJD)
request were submitted to the USACE on 5/17/21 to the US Army Corps of Engineers(USAGE).The
AJD request included a roadside ditch;the remaining project area was included in the PJD request.
Through email correspondence with Samantha Dailey(previous USACE representative for the
project),it was communicated that she agreed with the delineation.On 8/30/21,during the request
review by the USACE,the 2020 Navigable Waters Protection Rule was vacated which caused the
USACE to pause on issuing new AJDs.During a conversation with Lyle Phillips with the USACE(new
representative for the project),it was decided a PJD for the entire project would suffice.Because a
PJD is now being requested for the project,the roadside ditch(Ditch DA)is now considered
potentially jurisdictional.At the time of the site visit,an ordinary high water mark was observed in the
ditch.The ditch drains directly into Wetland WB.At the time of this permit application,a signed JD
has not been issued.
5b.If the Corps made a jurisdictional determination,what type of determination was made?*
Preliminary Approved Not Verified Unknown N/A
Corps AID Number:
SAW-2021-01055
5c.If 5a is yes,who delineated the jurisdictional areas?
Name(if known): Amanda Johnson,PWS
Agency/Consultant Company: WSP USA
Other:
6.Future Project Plans
6a.Is this a phased project?*
Yes No
Are any other NWP(s),regional general permit(s),or individual permits(s)used,or intended to be used,to authorize any part of the proposed project or related activity?
D. Proposed Impacts Inventory U
1. Impacts Summary
1a.Where are the impacts associated with your project?(check all that apply):
Wetlands Streams-tributaries Buffers
Open Waters Pond Construction
2.Wetland Impacts

2a1 Reason(?) 2b.Impact type*(?) 2c.Type of W. 2d.W.name* 2e.Forested �2f.Type of Jurisdicition*2g•Impact
W1 Construction Easement T Small-Basin Wetland ESite
WC(Impact No Both acres)
2g.Total Temporary Wetland Impact 2g.Total Permanent Wetland Impact
0.020 0.000
2g.Total Wetland Impact
0.020
21.Comments:
The wetland is a stormwater basin that is periodically mowed.Some of the area at the inlet of culvert where the temporary impacts are being proposed is
covered with riprap.
3. Stream Impacts
❑3a.Reason for impact(?) 3b.lmpact type* 3c.Type of impact* 3d.S.name* 3e.Stream Type* [3f.Type of 3g S width* 3h.Impact
(?) urisdiction* length*
S1 Channel Stabilization Permanent Bank Stabilization Stream SB(Impact Site S1) Perennial Both 16
Average(feet) (linear feet)
S2 Channel Stabilization Temporary Bank Stabilization J
Stream SB(Impact Site S1) Perennial Both 36
Average(feet) (linear feet)
S3 Rip rap at Embankment Permanent Bank Stabilization J
Stream SB(Impact Site S1) Perennial Both 13
Average(feet) (linear feet)
S4 Rip rap at Embankment Temporary Bank Stabilization J
Stream SB(Impact Site S1) Perennial Both 2 9
Average(feet) (linear feet)
S5 48"Pipe Replacement and Permanent Culvert Stream SB(Impact Site S1) Perennial Both 2 7
Extension Average(feet) (linear feet)
S6 48"Pipe Replacement and Permanent Culvert Stream SB(Impact Site S2) Intermittent Both 22
Extension Average(feet) pinear feet)
g7 48"Pipe Outlet Stabilization Permanent Bank Stabilization JZnn SB(Impact Site S2) Intermittent Both 16
Average(feet) (linear feet)
gg 48"Pipe Outlet Stabilization Temporary Bank Stabilization J
Stream SB(Impact Site S2) Intermittent Both 2 7
Average(feet) (linear feet)
S9 30"Pipe Extension Permanent Culvert Stream SA(Impact Site S3) Intermittent Both 16
Average(feet) (linear feet)
S10 Pipe Outlet Stabilization Permanent Bank Stabilization J
Stream SA(Impact Site S3) Intermittent Both 10
Average(feet) pinear feet)
S71 Pipe Outlet Stabilization Temporary Bank Stabilization Stream SA(Impact Site S3) Intermittent Both 2 7
Average(feet) (linear feet)
S12 Roadway Fill Slope Permanent::]Fill Ditch DA(Impact Site S4) Jurisdictional Ditch Both 1 38
Average(feet) (linear feet)
31.Total jurisdictional ditch impact in square feet:
38
3i.Total permanent stream impacts: 3i.Total temporary stream impacts:
138 59
31.Total stream and ditch impacts:
197
3j.Comments:
Total proposed permanent stream impacts include 45 linear feet of culvert fill impact and 55 linear feet of stream bank stabilization.Total proposed
temporary stream impacts include 59 linear feet.Total proposed impacts to a roadside jurisdictional ditch are 38 linear feet.
6. Buffer Impacts (for DWR)
6a.Project is in which protect basin(s)?
Check all that apply.
Neuse Tar-Pamlico
Catawba Randleman
Goose Creek Jordan Lake
Other
6b.Impact Type 6c.Per or Temp 6d.Stream name 6e.Buffer mitigation required? 6f.Zone 1 impact 6g.Zone 2 impact

48"Crosspipe&'V'Ditch P Stream SB(Impact Site 61) No 494 291
48"Crosspipe&'V Ditch P Stream SB(Impact Site B1) Yes 1,594 700
48"Crosspipe&'V Ditch P Stream SB(Impact Site 132) No 1,962 11 1,229
30"Pipe Collar and Extend P Stream SA(Impact Site B3) No 2,045 1,293
Lateral Variable Base Ditch P Stream SB(Impact Site 64) No 613 982
Special Cut'V'Ditch P Stream SB(Impact Site B5) No 572 516
6h. Total buffer impacts:
Zone 1 Zone 2
Total Temporary impacts: 0.00 0.00
Zone 1 Zone 2
Total Permanent impacts: 7,280.00 5,011.00
Zone 1 Zone 2
Total combined buffer impacts: 7,280.00 5,011.00
6i.Comments:
Zone 1 impacts requiring mitigation are 1,594 square feet at a 3:1 ratio,which totals 4,782 square feet.Zone 2 impacts requiring mitigation are 700
square feet at a 1.5:1 ratio,which totals 1,050 square feet.The total amount of required buffer mitigation credits for Zone 1 and Zone 2 impacts is 5,832
square feet.
E. Impact Justification and Mitigation
1.Avoidance and Minimization
la.Specifically describe measures taken to avoid or minimize the proposed impacts in designing the project:
The construction easement boundaries were designed at the northern end of the project along Shepard School Road to avoid impacts to the wetlands
on either side of the road(Wetlands WA and WB).By not replacing the 30"RCP-III at Impact Site S3,impacts to the Wetland WC(Impact Site W1)will
be minimized to temporary fill impacts for roadway construction.Fill slopes were designed to avoid permanent impacts to Wetland WC(Impact Site W1).
The construction easement boundaries were adjusted at Impact Site B1 to minimize impacts to the riparian buffer along Stream SB.
During the design,2:1 roadway slopes at stream crossing Impact Sites S1,S2 and S3 were considered but were not determined to be practicable.
Roadway slopes within the clear zone adjacent to the paved roadway must be maintained at 4:1 for vehicle recovery requirements,otherwise guardrail is
needed which requires wider shoulders.At Impact Sites S1,S2 and S3,it was determined that stream impacts resulting from 4:1 roadway slopes versus
2:1 roadway slopes with a widened shoulder and guardrail would be approximately the same.Therefore,the design includes 4:1 slopes at these impact
sites.Near Station-L-21+50 where Stream SB crosses Shepard School Road,a 3:1 slope is proposed to avoid impacts to the stream.
1 b.Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques:
All construction activities will be performed in accordance with the applicable requirements of the 2018 NCDOT Standard Specifications for Roads and
Structures.The erosion and sediment control plans will comply with the regulations set forth by the NGG-010000 General Construction Permit.
Erosion control devices such as silt fence and matting will also be utilized to minimize water quality impacts.
In locations where temporary construction activities will take place in the stream,the stream bed will be restored to pre-construction contours.Other
disturbed areas will be stabilized with vegetation by seeding and mulching.Temporary stream crossings will occur in the location of the permanent
stream impacts.
2.Compensatory Mitigation for Impacts to Waters of the U.S.or Waters of the State
2a.Does the project require Compensatory Mitigation for impacts to Waters of the U.S.or Waters of the State?
Yes No
2b.If this project DOES NOT require Compensatory Mitigation,explain why:
Lyle Phillips with the USACE indicated stream mitigation would not be required for this proposed project if total permanent stream impacts are less than 150 linear feet.Because total
permanent impacts that would result in a loss of Waters of the US(WOTUS)are 83 linear feet,mitigation is not proposed for this project.There are no permanent impacts to wetlands and
therefore wetland mitigation will not be required for this proposed project.
Because impacts will not exceed 300 linear feet per perennial stream or 0.10 acre of wetlands,mitigation will not be required by NCDWR for the proposed project.
F. Stormwater Management and Diffuse Flow Plan (required by DWR) u
1. Diffuse Flow Plan
1a.Does the project include or is it adjacent to protected riparian buffers identified within one of the NC Riparian Buffer Protection Rules?
Yes No

What type of SCM are you providing?
Level Spreader
Vegetated Conveyance(lower SHWT)
Wetland Swale(higher SHWT)
Other SCM that removes minimum 30%nitrogen
Proposed project will not create concentrated stormwater flow through the buffer
2. Stormwater Management Plan
2a.Is this a NCDOT project subject to compliance with NCDOT's Individual NPDES permit NCS000250?
Yes No
Comments:
Because this project is on NCDOT owned roadway,the project will be administered through NCDOT and all design has been done to their standards.
G. Supplementary Information
1. Environmental Documentation
la.Does the project involve an expenditure of public(federal/state/local)funds or the use of public(federal/state)land?
Yes No
1 b.If you answered"yes"to the above,does the project require preparation of an environmental document pursuant to the requirements of the National or State(North Carolina)
Environmental Policy Act(NEPA/SEPA)?*
Yes No
Comments:
The Town of Zebulon is providing the 100%funding for this project.No NCDOT,FHWA,or other state/federal grants will be funding this project.
2.Violations (DWR Requirement)
2a.Is the site in violation of DWR Water Quality Certification Rules(15A NCAC 2H.0500),Isolated Wetland Rules(15A NCAC 2H.1300),or DWR Surface Water or Wetland Standards or
Riparian Buffer Rules(15A NCAC 2B.0200)?*
Yes No
3. Cumulative Impacts (DWR Requirement)
3a.Will this project result in additional development,which could impact nearby downstream water quality?
Yes No
4. Sewage Disposal (DWR Requirement)
4a.Is sewage disposal required by DWR for this project?*
Yes No N/A
5. Endangered Species and Designated Critical Habitat(Corps Requirement)
5a.Will this project occur in or near an area with federally protected species or habitat?*
Yes No
5b.Have you checked with the USFWS concerning Endangered Species Act impacts?*
Yes No
5d.Is another Federal agency involved?*
Yes No Unknown
5e.Is this a DOT project located within Division's 1-8?
Yes No

5j.What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical Habitat?
WSP USA contacted the US Fish and Wildlife Service through the Information for Planning and Consultation(IPaC)system to retrieve an official species
list of threatened and endangered species protected under the Endangered Species Act(ESA)for the proposed project.Six species are listed:red-
cockaded woodpecker(endangered),Neuse River waterdog(threatened),Carolina madtom(endangered),Atlantic pigtoe(proposed threatened),Dwarf
wedgemussel(endangered),and Michaux's sumac(endangered).No critical habitat was shown to occur within the project area.No records of protected
species within or within one mile of the project were shown in the NC Natural Heritage Program(NCNHP)report generated on 11/4/21.
Habitat surveys were conducted by WSP USA for the above listed species on 4/7/21.No suitable habitat was present in the project area;therefore,the
project will have no effect on the ESA-protected species.
Suitable habitat is not present for red-cockaded woodpecker because no mature pine stands are present in the project area.
Suitable habitat is not present for Neuse River waterdog,Carolina madtom,Atlantic pigtoe,and dwarf wedgemussel due to the presence of intermittent
streams and low Flows and low dissolved oxygen in perennial streams.The perennial sections of Stream SB are directly connected to impoundments
outside of the project area,which would have low dissolved-oxygen levels.The perennial segments had low flow,sections of shallow water depths
during a period of non-dry/non-drought conditions,evidence of sedimentation,and predominantly sandy streambeds.Iron oxidizing bacteria were
observed throughout the perennial stream segments,suggesting slow/stagnant sections of water.The intermittent stream segments would not provide
suitable habitat because the species are all aquatic and require water to survive.
Suitable habitat is not present for Michaux's sumac because the project area consisted of densely forested areas,wetlands with open canopies,
agricultural fields,regularly mowed grassy roadway right-of-way,and a powerline corridor overgrown with dense thickets for blackberry shrubs.
The IPaC official species list and NCNHP report are included in an appendix for this permit application.
6. Essential Fish Habitat(Corps Requirement)
6a.Will this project occur in or near an area designated as an Essential Fish Habitat?"
Yes No
6b.What data sources did you use to determine whether your site would impact an Essential Fish Habitat?"
National Oceanic and Atmospheric Essential Fish Habitat Mapper
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a.Will this project occur in or near an area that the state,federal or tribal governments have designated as having historic or cultural preservation status?*
Yes No
7b.What data sources did you use to determine whether your site would impact historic or archeological resources?*
Initial review included the HPOWEB 2.0 web mapping application.WSP USA submitted an environmental review request letter to the North Carolina
State Historic Preservation Office(SHPO)on 9/7/21.In a response letter received on 10/12/21,SHPO stated no historic resources would be affected by
the project.The response letter is included in an appendix for this permit application.
8. Flood Zone Designation (Corps Requirement)
8a.Will this project occur in a FEMA-designated 100-year floodplain?"
Yes No
8c.What source(s)did you use to make the floodplain determination?"
The flood.NC.gov Property Risk web mapping application.
Miscellaneous
Please use the space below to attach all required documentation or any additional information you feel is helpful for application review.Documents should be combined into one file when
possible,with a Cover Letter,Table of Contents,and a Cover Sheet for each Section preferred.
Click the upload button or drag and drop files here to attach document
Intersection Improvements at SR 2320 and Shepard School Road ePCN Cover Letter and Appendices.pdf 10.12MB
File must be PDF or KMZ
Comments
Please see the attached cover letter and appendices for additional information.
Signature
By checking the box and signing below,I certify that:
• The project proponent hereby certifies that all information contained herein is true,accurate,and complete to the best of my knowledge and belief';and
• 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 have given true,accurate,and complete information on this form;
• I agree that submission of this PCN 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 PCN form.
Full Name:
Amanda Johnson

Signature
(y'fn d.1?1/-Awe
Date
11/30/2021