20071384 Ver 1_Application_20070813

Office Use Only: Form Version February 2002
07'- 1 3g4
USACE Action ID No. DWQ No.
If any particular item is not applicable to this project, please enter "Not Applicable" or "N/A" rather than
leaving the space blank.
P A I I~
I. Processing
Check all of the approval(s) requested for this project:
® Section 404 Permit
^ Section 10 Permit
® 401 Water Quality Certification
^ Riparian or Watershed Buffer Rules
2. Nationwide, Regional or General Permit Number(s) Requested: NW 27, NW 33, NW 43
3. If this notification is solely a courtesy copy because written approval for the 401 Certification
is not required, check here: ^
4. If payment into the North Carolina Wetlands Restoration Program (NCWRP) is proposed for
mitigation of impacts (see section VIII -Mitigation), check here: ^ D ~ ~ ~ ~~~
II. Applicant Information
AUG 1 u 2007
1. Owner/Applicant Information DENR - WATER QtiALiTY
Name: City of Winston-Salem (Attn: Keith Huffl w~nArx~au~srrn~naa*FasRrwcH
Mailing Address: 101 North Main Street
Suite 53
Winston-Salem. NC 27101
Telephone Number: 336-747-6962 Fax Number: 336-748-3173
E-mail Address: keithhl~a cityofws.or~
2. Agent Information (A signed and dated copy of the Agent Authorization letter must be
attached if the Agent has signatory authority for the owner/applicant.)
Name: Rocky Powell
Company Affiliation: Clear Creeks Consulting LLC
Mailing Address: 1317 Knopp Road
Jarrettsville MD 21084
Telephone Number: [phone] Fax Number: [phone]
E-mail Address: clearcreeks(cr~clearviewcatv.net
Page 5 of 16

III. Project Information
Attach a vicinity map clearly showing the location of the property with respect to local
landmarks such as towns, rivers, and roads. Also provide a detailed site plan showing property
boundaries. and development plans in relation to surrounding properties. Both the vicinity map
and site plan must include a scale and north arrow. The specific footprints of all buildings,
impervious surfaces, or other facilities must be included. If possible, the maps and plans should
include the appropriate USGS Topographic Quad Map and NRCS Soil Survey with the property
boundaries outlined. Plan drawings, or other maps maybe included at the applicant's discretion,
so long as the property is clearly defined. For administrative and distribution purposes, the
USACE requires information to be submitted on sheets no larger than 11 by 17-inch format;
however, DWQ may accept paperwork of any size. DWQ prefers full-size construction
drawings rather than a sequential sheet version of the full-size plans. If full-size plans are
reduced to a small scale such that the final version is illegible, the applicant will be informed that
the project has been placed on hold until decipherable maps are provided.
1. Name of project: Bath Branch Stream Valley Restoration
2. T.I.P. Project Number or State Project Number (NCDOT Only):
3. Property Identification Number (Tax PIN):
4. Location
County: Forsyth Nearest Town: Winston-Salem
Subdivision name (include phase/lot number): NA
Directions to site (include road numbers, landmarks, etc.): I40 West, Rte 152 North,
Stadium Drive West
5. Site coordinates, if available (UTM or Lat/Long): 36°05'24.13" N, 80°13'58.99"
(Note - If project is linear, such as a road or utility line, attach a sheet that separately lists the
coordinates for each crossing of a distinct waterbody.)
6. Describe the existing land use or condition of the site at the time of this application:
Highly urban -East Winston Salem Commercial/Industrial land and City Maintenance Yard
7. Property size (acres):
8. Nearest body of water (stream/river/sound/ocean/lake): Bath Branch/Salem Creek
9. River Basin: Yadkin Pee-Dee River
(Note -this must be one of North Carolina's seventeen designated major river basins. The
River Basin map is available at htt~://h2o.cnr.state.nc.us/adminhnaps/.)
Page 6 of 16

10. Describe the purpose of the proposed work:
Restore 22001inear feet of Bath Branch by utilizing a natural channel design approach; Remove
concrete rubble fill from floodplain and valley side slopes; Provide quantity and quality storm
water management for 491 acres of unmanaged urban watershed by creating three regional storm
water wetland ponds.
11. List the type of equipment to be used to construct the project:
Tracked excavators with hydraulic thumbs, tracked trucks and tracked loaders, dump trucks and
misc. small trucks.
12. Describe the land use in the vicinity of this project:
Although the stream corridor along much of Bath Branch downstream of U.S. Business 40 is
wooded, the dominant land use in the upper watershed is industrial (light manufacturing), high
density commercial uses (e.g., office buildings, small businesses, restaurants, etc.), highway and
streets, and a smaller percentage of single family residential and moderate to high density multi-
family residential situated in the neighborhoods east of Route 52. With the exception of a 50
foot open channel section, the original Bath Branch upstream of U. S. Business 40 was enclosed
in an extensive piped storm drain system when the area was filled in the late 1960's to
accommodate the interchange of U. S. Business 40 and Route 52, expansion of the rail yard, and
development of manufacturing facilities.
IV. Prior Project History
If jurisdictional determinations and/or permits have been requested and/or obtained for this
project (including all prior phases of the same subdivision) in the past, please explain. Include
the USACE Action ID Number, DWQ Project Number, application date, and date permits and
certifications were issued or withdrawn. Provide photocopies of previously issued permits,
certifications or other useful information. Describe previously approved wetland, stream and
buffer impacts, along with associated mitigation (where applicable). If this is a NCDOT project,
list and describe permits issued for prior segments of the same T.I.P. project, along with
construction schedules.
A pre-application meeting was held on-site May 2, 2007 to present the project to the permitting
agencies. The following persons were in attendance: Mr. John Thomas, USACOE; Mr. Daryl
Lamb, NC DWQ; Mr. Ian McMillan, NC DWQ; Mr. Eric Kulz, NC DWQ; Mr. Clif Whitfield,
NC DLQ; Mr. Keith Huff, City of Winston Salem; Mr. Rocky Powell, Clear Creeks Consulting,
Mr. Carl Corse, and Mr. Christopher Stepp, CNA Engineers.
V. Future Project Plans
Are any future permit requests anticipated for this project? If so, describe the anticipated work,
and provide justification for the exclusion of this work from the current application.
None anticipated
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VI. Proposed Impacts to Waters of the United States/Waters of the State
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
wetlands, open water, and stream channels associated with the project. The applicant must also
provide justification for these impacts in Section VII below. All proposed impacts, permanent
and temporary, must be listed herein, and must be clearly identifiable on an accompanying site
plan. All wetlands and waters, and all streams (intermittent and perennial) must be shown on a
delineation map, whether or not impacts are proposed to these systems. Wetland and stream
evaluation and delineation forms should be included as appropriate. Photographs may be
included at the applicant's discretion. If this proposed impact is strictly for wetland or stream
mitigation, list and describe the impact in Section VIII below. If additional space is needed for
listing or description, please attach a separate sheet.
1. Provide a brief written description of the proposed impacts:
Temporary impacts include: 1) Removal of existing vegetation along the stream corridor to
remove exotic and invasive plant species and at various points along Bath Branch to allow
removal of rubble fill, grading, sloping, and matting of the banks.
Permanent impacts include: 1) Placement of fill along 1079 feet of deeply incised perennial
stream to raise the streambed, reconnect the channel with its floodplain and provide grade
control by installing log-boulder step pools and boulder cascades; and 2) placement of fill in 50
linear feet intermittent channel section to construct 7 acre stormwater wetland.
2. Individually list wetland impacts below:
Wetland Impact
Site Number
(indicate on ma)
Type of Impact* Area of
Impact
(acres) Located within
100-year Floodplain**
(yes/no) Distance to
Nearest Stream
(linear feet)
Type of Wetland***

* List each impact separately and identity temporary impacts. Impacts include, but are not limited to: mechanized clearing, gractmg, i~11,
excavation, flooding, ditching/drainage, etc. For dams, separately list impacts due to both structure and flooding.
** 100-Year floodplains are identified through the Federal Emergency Management Agency's (FEMA) Flood Insurance Rate Maps
(FIRM), or FEMA-approved local floodplain maps. Maps are available through the FEMA Map Service Center at 1-800-358-9616, or
online at http:iiwww.fema.gov.
*** List a wetland type that best describes wetland to be impacted (e.g., freshwater/saltwater marsh, forested wetland, beaver pond,
Carolina Bay, bog, etc.)
List the total acreage (estimated) of all existing wetlands on the property: 0.0 acres
Total area of wetland impact proposed: 0.0 acres
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3. Individually list all intermittent and perennial stream impacts below:
Stream Impact
Length of Average
Perennial or
Site Number Type of Impact **
Stream Name Width of Intermittent?
(indicate on *
Impact
(linear feet) Stream Before
(Please specify)
map) Impact
Relocate 1971 ft pipe x
Piped Storm aft wide flow
1 Drain to in pipe = 5913 Bath Branch 3 ft Intermittent
SWM Pond ft2 = 0.135
acres
2 SWM Pond 50 ft Bath Branch 3 ft Intermittent
3 Restoration 2199 ft Bath Branch 15 ft Perennial
* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: culverts and associated rip-rap,
dams (separately list impacts due to both structure and flooding), relocation (include linear feet before and after, and net loss/gain),
stabilization activities (cement wall, rip-rap, crib wall, gabions, etc.), excavation, ditching/straightening, etc. If stream relocation is
proposed, plans and profiles showing the linear footprint for both the original and relocated streams must be included.
** Stream names can be found on USGS topographic maps. If a stream has no name, list as UT (unnamed tributary) to the nearest
downstream named stream into which it flows. USGS maps are available through the USGS at 1-800-358-9616, or online at
www.uss.gov. Several Internet sites also allow direct download and printing of USGS maps (e.g., w~~~~~.topozone.com,
www.ma~quest.com, etc.).
Cumulative impacts (linear distance in feet) to all streams on site: 2249 feet
4. Individually list all open water impacts (including lakes, ponds, estuaries, sounds, Atlantic Ocean
and any other water of the U.S.) below:
Open Water Impact

Site Number
(indicate on ma)
*
Type of Impact Area of

Impact
(acres
Name of Waterbody
(if applicable) Type of Waterbody

(lake, pond, estuary, sound,
bay, ocean, etc.

* List each impact separately and identify temporary impacts. Impacts include, but are not limited to: fill, excavation, dredging,
flooding, drainage, bulkheads, etc.
5. Pond Creation
If construction of a pond is proposed, associated wetland and stream impacts should be included
above in the wetland and stream impact sections. Also, the proposed pond should be described here
and illustrated on any maps included with this application.
Pond to be created in (check all that apply): ®uplands ®stream ^ wetlands
Describe the method of construction (e.g., dam/embankment, excavation, installation of draw-down
valve or spillway, etc.):
Page 9 of 16

1. The Southern District Stormwater Wetland Pond will be an excavated facility with a 0.79 acre
permanent pool, a forebay at the inlet to the facility, amicro-pool at the outlet to the facility, and
a wetland bench around the perimeter of the permanent pool. Concrete weir walls will provide
structural control between the forebay and permanent pool, and the micro-pool and permanent
pool. A 5' x 5' concrete riser structure with a 36" RCP spillway will provide detention for the
temporary water quality volume and smaller storm events. An earthen spillway will function as
an emergency spillway for large storm events. Construction of this stormwater retrofit facility
involves removal of paving, more than 1.5 acres of excavation in the existing City Maintenance
Yard, and relocation of the existing storm drain system. The outside perimeter of the wetland
facility has a riparian buffer of native grasses, trees and shrubs. The facility is situated in uplands
outside of the 100-yr floodway and floodplain of Salem Creek.
2. The Credit Union Stormwater Wetland Pond will be an excavated facility with a 0.80 acre
permanent pool, a forebay at the inlet to the facility, amicro-pool at the outlet to the facilty, and
a wetland bench around the perimeter of the permanent pool. Concrete weir walls will provide
structural control between the forebay and permanent pool, and the micro-pool and permanent
pool. A 5' x 5' concrete riser structure with a 36" RCP spillway will provide detention for the
temporary water quality volume and smaller storm events. An earthen spillway will provide
hydrologic conductivity between the facility and Salem Creek in the event of flooding.
Construction of this stormwater retrofit facility involves more than 2.0 acres of excavation in the
vacant lot at the rear of the City Credit Union site, and relocation of the existing storm drain
system. The outside perimeter of the wetland facility has a riparian buffer of native grasses, trees
and shrubs. The facility is situated in uplands but within the 100-yr floodway and floodplain of
Salem Creek.
3. The Central District Stormwater Wetland Pond includes an upper cell that has a permanent
pool surface area of 1.23 acres and a lower cell with a permanent pool surface area of 2.13 acre.
Each cell has a forebay at the inlet to the cell, amicro-pool at the outlet to the cell, and a wetland
bench around the perimeter of the permanent pool. Concrete weir walls will provide structural
control between the forebay and permanent pool, and the micro-pool and permanent pool in each
cell. Both cells have in-pipe pretreatment systems that remove mass solids and trash. A 10' x
10' concrete riser structure will be constructed onto an existing 10' x 10' concrete box culvert
that conveys runoff underneath Business I-40. The riser structure has a dual low flow device with
10" orifices to provide temporary water quality volume of 17.98 ac-ft with a 24-hour drawdown
time. The outside perimeter of the wetland facility has a riparian buffer of native grasses, trees
and shrubs. Construction of this stormwater retrofit facility involves demolition and removal of
existing industrial buildings, excavation of more than 7.0 acres of existing paving, and relocation
of the existing storm drain system and several utilities including an 18" sanitary sewer upgrade
that runs through the outlet culvert.
Proposed use or purpose of pond (e.g., livestock watering, irrigation, aesthetic, trout pond, local
stormwater requirement, etc.):
The goal of the three (3) regional stormwater retrofits is to provide quantity and quality storm
water management for 491 acres of unmanaged urban watershed.
Page 10 of 16

Size of watershed draining to pond: Expected pond surface area: Associated impacts:
o Southern District Stormwater Wetland Pond: DA - 65 acres, SA - 1.3 acres
• Wetlands -none
• Stream -none
o Credit Union Stormwater Wetland Pond: DA - 71 acres, SA - 1.7 acres
• Wetlands -none
• Stream -none
o Central District Stormwater Wetland Pond: DA - 355 acres, SA - 6.4 acres
• Wetlands -none
Stream - SO linear feet, Type -Intermittent
VII. Impact Justification (Avoidance and Minimization)
Specifically describe measures taken to avoid the proposed impacts. It maybe useful to provide
information related to site constraints such as topography, building ordinances, accessibility, and
financial viability of the project. The applicant may attach drawings of alternative, lower-impact
site layouts, and explain why these design options were not feasible. Also discuss how impacts
were minimized once the desired site plan was developed. If applicable, discuss construction
techniques to be followed during construction to reduce impacts.
The general restoration approach includes installing stormwater wetland ponds to provide water
quality and quantity management for a highly urbanized watershed and reconstructing reaches of
the Bath Branch remove historic floodplain fill, reconnect the channel with the floodplain, and
stabilize eroding streambanks and valley slopes.
The temporary impacts associated with mechanical clearing will remove dense growth of exotic
and invasive plant species and allow access for grading eroding stream banks. All disturbed
areas impacted within the limits of the project will be seeded with native grasses and planted
with native trees and shrubs. All disturbed areas impacted outside the limits of the project will be
seeded with grasses and clover.
The permanent impacts are associated with fill. The majority of the fill placed will involve
placing boulder, cobble and gravel backfill to raise the streambed and reconnect the channel to
its floodplain and reconstructing narrower channel cross-sections to improve habitat and
sediment transport. In addition, log-boulder step-pools will be constructed along the lower reach
where the streambed will be raised significantly. Avoidance of these impacts would be
inconsistent with many of the objectives of this project including: reconnecting the stream
channels with their floodplain, improving habitat by constructing a narrower and deeper
baseflow channel, improving sediment transport capacity, reducing sedimentation, and protecting
the stream banks from scour.
The design of the Central District Stormwater Wetland Pond was developed with the goal of
maximizing reductions in pollutant loadings and peak discharges to Bath Branch. It includes an
upper cell that has a permanent pool surface area of 1.23 acres and a lower cell with a permanent
pool surface area of 2.13 acre. Each cell has a broad wetland bench. Both cells have in-pipe
Page 11 of 16

pretreatment systems that remove mass solids and trash, as well as deep forebays for particulate
removal. The perimeter of the wetland facility has a riparian buffer of native grasses, trees and
shrubs.
Construction of this stormwater retrofit facility involves demolition and removal of existing
industrial buildings, excavation of more than 7.0 acres of existing paving, and relocation of the
existing storm drain system. There will be no wetland impacts associated with the Central
District stormwater retrofit. Impacts are limited to 50 feet of open channel (with intermittent
stream flow) in a system where 99% of the original stream channel was piped prior to 1968.
Results of flow monitoring conducted in the storm drain system and Bath Branch confirmed that
base flow is intermittent upstream of the culvert at U.S. Business 40. Mid way through the
culvert beneath U.S. Business 40 drainage from the watershed east of Route 52 joins the system.
From this point downstream baseflow is perennial
The selection of the location for the Central District stormwater retrofit was based on several
factors. Locating the facility upstream of US Business 40 positioned it at the downstream end of
the piped storm drain system that conveys stormwater runoff from downtown Winston Salem
into Bath Branch. This allowed for quality and quantity management of the maximum possible
drainage area while still avoiding the open and perennial sections of Bath Branch downstream of
US Business 40. The fact that the land was donated to the City of Winston Salem specifically
for the stormwater retrofit, allowing the City a significant savings in public funds, was also a
major consideration.
VIII. Mitigation
DWQ - In accordance with 15A NCAC 2H .0500, mitigation may be required by the NC
Division of Water Quality for projects involving greater than or equal to one acre of impacts to
freshwater wetlands or greater than or equal to 150 linear feet of total impacts to perennial
streams.
USACE - In accordance with the Final Notice of Issuance and Modification of Nationwide
Permits, published in the Federal Register on March 9, 2000, mitigation will be required when
necessary to ensure that adverse effects to the aquatic environment are minimal. Factors
including size and type of proposed impact and function and relative value of the impacted
aquatic resource will be considered in determining acceptability of appropriate and practicable
mitigation as proposed. Examples of mitigation that maybe appropriate and practicable include,
but are not limited to: reducing the size of the project; establishing and maintaining wetland
and/or upland vegetated buffers to protect open waters such as streams; and replacing losses of
aquatic resource functions and values by creating, restoring, enhancing, or preserving similar
functions and values, preferable in the same watershed.
If mitigation is required for this project, a copy of the mitigation plan must be attached in order
for USACE or DWQ to consider the application complete for processing. Any application
lacking a required mitigation plan or NCWRP concurrence shall be placed on hold as
incomplete. An applicant may also choose to review the current guidelines for stream restoration
Page 12 of 16

in DWQ's Draft Technical Guide for Stream Work in North Carolina, available at
http://h2o.enr.state.nc.usincwetlandsistrm~ide.html.
1. Provide a brief description of the proposed mitigation plan. The description should provide
as much information as possible, including, but not limited to: site location (attach directions
and/or map, if offsite), affected stream and river basin, type and amount (acreage/linear feet)
of mitigation proposed (restoration, enhancement, creation, or preservation), a plan view,
preservation mechanism (e.g., deed restrictions, conservation easement, etc.), and a
description of the current site conditions and proposed method of construction. Please attach
a separate sheet if more space is needed.
Given the type of project it is not anticipated that mitigation will be required. In fact, the
project itself could be viewed as mitigation for historic land use impacts to Bath Branch. As
a result of this project 491 acres of highly urbanized watershed will be managed for water
quality and quantity, 1.5 acres of wetlands will be created, 2200 feet of eroding stream
channel will be stabilized, and sediment and nutrient loadings to the Salem Creek and the
Yadkin Pee Dee River resulting from urban runoff and eroding streambanks will be
significantly reduced. In addition, the project will establish a 20 acre conservation easement
that permanently protects the stormwater wetlands, stream, and riparian corridor.
In particular the Central District regional stormwater retrofit will manage 355 acres of
downtown Winston Salem (67 % impervious surfaces). It will provide a 70% reduction in
pollutant loadings from the total drainage area and reduce the 1-YR and 2-YR peak
discharges by 78% and 64%, respectively.
2. Mitigation may also be made by payment into the North Carolina Wetlands Restoration
Program (NCWRP) with the NCWRP's written agreement. Check the box indicating that
you would like to pay into the NCWRP. Please note that payment into the NCWRP must be
reviewed and approved before it can be used to satisfy mitigation requirements. Applicants
will be notified early in the review process by the 401/Wetlands Unit if payment into the
NCWRP is available as an option. For additional information regarding the application
process for the NCWRP, check the NCWRP website at httP:;';h2o.c,Ir.state.nc.usi'wrplindex.hm~. If
use of the NCWRP is proposed, please check the appropriate box on page three and provide
the following information:
Amount of stream mitigation requested (linear feet):
Amount of buffer mitigation requested (square feet):
Amount of Riparian wetland mitigation requested (acres):
Amount ofNon-riparian wetland mitigation requested (acres):
Amount of Coastal wetland mitigation requested (acres):
IX. Environmental Documentation (DWQ Only)
Does the project involve an expenditure of public (federal/state) funds or the use of public
(federal/state) land?
Yes ® No ^
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If yes, does the project require preparation of an environmental document pursuant to the
requirements of the National or North Carolina Environmental Policy Act (NEPA/SEPA)?
Note: If you are not sure whether a NEPA/SEPA document is required, call the SEPA
coordinator at [phone] to review current thresholds for environmental documentation.
Yes ^ No
If yes, has the document review been finalized by the State Clearinghouse? If so, please attach a
copy of the NEPA or SEPA final approval letter.
Yes ^ No ^
X. Proposed Impacts on Riparian and Watershed Buffers (DWQ Only)
It is the applicant's (or agent's) responsibility to determine, delineate and map all impacts to
required state and local buffers associated with the project. The applicant must also provide
justification for these impacts in Section VII above. All proposed impacts must be listed herein,
and must be clearly identifiable on the accompanying site plan. All buffers must be shown on a
map, whether or not impacts are proposed to the buffers. Correspondence from the DWQ
Regional Office may be included as appropriate. Photographs may also be included at the
applicant's discretion.
Will the project impact protected riparian buffers identified within 15A NCAC 2B .0233
(Meuse), 15A NCAC 2B .0259 (Tar-Pamlico), 15A NCAC 2B .0250 (Randleman Rules and
Water Supply Buffer Requirements), or other (please identify )?
Yes ^ No ^ If you answered "yes", provide the following information:
Identify the square feet and acreage of impact to each zone of the riparian buffers. If buffer
mitigation is required calculate the required amount of mitigation by applying the buffer
multipliers.
Zone* Impact
(s uare feet Multiplier Required
Miti ation
1 3
2 1.5
Total
Gone 1 extends out 3U feet perpendicular from near bank of channel; Gone Z extends an
additional 20 feet from the edge of Zone 1.
If buffer mitigation is required, please discuss what type of mitigation is proposed (i.e., Donation
of Property, Conservation Easement, Riparian Buffer Restoration /Enhancement, Preservation or
Payment into the Riparian Buffer Restoration Fund). Please attach all appropriate information as
identified within 15A NCAC 2B .0242 or .0260.
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XI. Stormwater (DWQ Only)
Describe impervious acreage (both existing and proposed) versus total acreage on the site.
Discuss Stormwater controls proposed in order to protect surface waters and wetlands
downstream from the property.
Central District Stormwater Wetland Pond
Total Watershed - 355 acres
Impervious - 235.6 acres (existing), 235.6 acres (proposed)
This is a City sponsored regional Stormwater retrofit facility. The goal of implementing this
component of the overall restoration project is to protect downstream surface waters (i.e., Salem
Creek and Yadkin Pee Dee River) by reducing pollutant loadings from urban runoff and reducing
stream instability by controlling peak discharges.
XII. Sewage Disposal (DWQ Only)
Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of
wastewater generated from the proposed project, or available capacity of the subject facility.
XIII. Violations (DWQ Only)
Is this site in violation of DWQ Wetland Rules (15A NCAC 2H .0500) or any Buffer Rules?
Yes ^ No ^
Is this an after-the-fact permit application?
Yes ^ No ^
XIV. Other Circumstances (Optional):
It is the applicant's responsibility to submit the application sufficiently in advance of desired
construction dates to allow processing time for these permits. However, an applicant may
choose to list constraints associated with construction or sequencing that may impose limits on
work schedules (e.g., draw-down schedules for lakes, dates associated with Endangered and
Threatened Species, accessibility problems, or other issues outside of the applicant's control).
Page 15 of 16

lid/
a/~/~~
~ Applicant~~gent's Signature Date
(Agent's signature is valid only if an authorization letter from the applicant is provided.)
Page 16 of 16