20221576 Ver 1_401 Application submittal form_20221109

Staff Review Form
NORTH CAROLINA
Envlronm¢ntcl Qvofiry
Updated September 4, 2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
Yes No
ID# *
20221576
Version* 1
Is this project a public transportation project?*
Yes
• No
Reviewer List: * Sue Homewood:eads\slhomewood
Select Reviewing Office: *
Winston-Salem Regional Office - [phone]
Does this project require a request for payment to be sent?*
Yes
No
How much is owed?* $240.00
$570.00

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:
6/1/2022
Project Contact Information
Name:
Kristi Lynn Carpenter for Jason Hartshorn
Who is submitting the information?
Email Address: [e-mail]
Project Information
Existing ID #:
20221576
20170001 (no dashes)
Project Name: Project Blue HE-0006
Is this a public transportation project?
Yes
No
Existing Version:
1
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
Yes No Unknown
County (ies)
Chatham
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:
Original submitted via LF Forms and encountered a glitch in the system where it did not come through to the
401 Program. This may be a duplicated submission for the 404 Program. Application is too large for submission
through this form and will be located in the project folder.
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:
c)&----idez4mw
Submittal Date: Is filled in automatically.