HomeMy WebLinkAbout20211607 Ver 2_Application Attachments_20220506 o
0 vim.
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
20211607
Is this project a public transportation project?* Yes
No
Is this a DOT Yes No
project?*
Reviewer List:* Ryan Conchilla:eads\rjconchilla
Select Reviewing Office:* Central Office-(919)707-9000
Submittal Type:* Application Attachments
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 Date Request was submitted on:
Project Contact Information
...............................................................................................................................................................................................................
Name: Ray Bode
Who is submitting the information?
Email Address: rbode@jmt.com
Project Information
........................................ ..................................
Project Name: TIP 1-5898 U.S.220 at U.S.311/N.C. 135 Interchange and Replacement of Bridge
#780074
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#:
15898 46860.1.1
(Applies to DOT projects only)
County(ies)
Rockingham
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
1-5898 PCN-RGP 50.pdf 16.79MB
Only pdf or kmz files are accepted.
Describe the attachments or
comments:
PCN for RGP 50
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:
W.VOA fw OW, "
Submittal Date: Is filled in automatically.