20150795 Ver 1_SR 1222 - Bridge 20 - Division 11 - STR - WT 03 - Watauga_20151130

U.S. ARMY CflRPS OF ENGINEERS
Wilmington Distric#
Compensatory Miti�ation ResponsibilityTransfer Form
Permittee: PICDO7/Attn: Heath Slaughter Action ID: SAW-2015-02248
Projed Mame: NCDOT/Bridge20/SR1222/Div County: Watauga
lnstructions to Permittee: The Permittee must provide a copy of this form to the Mitigation Sp�nsor, either an approved
Mitigation Bank or the North Carolina Ecosystem Enhancement Program (NCEEP), who will then sign the farm to verify the
transfer of the mitigation responsibility. Once the Sponsor has signed this form, it is the Permittee's responsibility to
ensure that to the U.S. Army Corps of Engineers (USACE) Project Manager identified on page two is in receipt of a signed
copy of this form before conducting authorized impacts, unless otherwise specified below. If more'than one mitigation
Sponsor will be used to provide the mitigation associated with the permit, or if the impacts and/or the mitigation will occur
in more than one 8-digit Hydrologic Unit Code (HUC), multiple forms will 6e attached to the permit, and the separate forms
for each Sponsor and/or HUC must be provided to the appropriate mitigation Sponsors.
Ins#ructions to Sponsor: The Sponsor must verify that the mitigatian requirements (credits} shown below are available at
the identified site_ By signing below, the Sponsor is accepting full responsibility for the identified mitigation, regardless of
whether or not they have received payment from the Permittee. Once the form is signed, the Sponsor must update the
bank ledger and provide a copy of the signed form and the updated bank ledger to the Permittee, the USACE Project
Manager, and the Wilmington District Mitigation Office (see contact information on page 2). The Sponsor must also comply
with all reporting requirements established in their authorizing instrument.
Permitted Impacts and Compensatory Mitigation Requirements:
Permitted Impatts Requiring Mitigation* S-digit HUC and Basin: 060101D3, Watau�a River Basin
Stream Impacts (linear feet}
Warm Cool Cold
b0
Wetland I
rian Riverine � Riparian Non-Riverine � Non-Riparian � Coastal
#If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
ipensatory Mitigation I
Stream Mitigation
Warm Cool
nts: 8-digit HUC and Basin: 06010103, Watauga River
Wetland Mitigation (credits)
Cold Riparian Riverine Riparian Non-Riverine Non-Rip
120
Coastal
Mitigation Site Debited: NCDMS
(List the name of the bank #o be debited. For umbrella banks, also list the specific site. For NCEEP, list NCEEP. If the NCEEP
acceptance letter identifies a specific site, also list the specific site to be debited).
Section io be completed by the Mitigotion Sponsor
Statement of Mitigation Liability Acceptance: I, the undersigned, verify that I am authorized to approve mitigation
transactions for the Mitigation Sponsor shown below, and t certify that the Sponsor agrees to accept full responsibility for
providing the mitigation identified in this document (see the table above),'associated with the USACE Permittee and Action
ID number shown. ! also verify that released credits (and/or advance credits for NCEEP), as approved by the USACE, are
currently available at the mitigation site identified above. Further, I understand that if the Sponsor fails to provide the
required compensatory mitigation, the USACE Wilrningtfln District Engineer may pursue measures against the Sponsor to
ensure compliance associated with the mitigation requirements.
Mitigation Sponsor Name:,
Name Sponsor's Authorized Representative: ��-{�i� `f"��'(,�
� �
S nature of 5pansor's Authorized Representative
Page 1 of 2 Form Updated 12 September, 2014

USACE Wilmington District
Compensatory Mitigation Responsibility Transfer �orm, Page 2
Conditions for Transfer of Compensatory Mi.tigation Credit:
• Once this document has been signed by the Mitigation Sponsor and the USACE is in receipt of the signed farm, the
Permittee is no longer respansible for providing the mitigation identified in this form, though the Permittee remains
responsible for any other mi#igation requirements stated in the permit conditions.
• Construction within jurisdictional areas authorized by the permit identified on page one of this form can begin only
after the USACE is in receipt of a copy of this document signed by the Sponsor, confirming that the Sponsor has
accepted responsibility for providing the mitigation requirements listed herein. For authorized impacts conducted by
the North Carolina Department of Transportation (NCDOT}, construction within jurisdictional areas may proceed upon
permit issuance; however, a copy of this form signed by the Sponsor must be provided to the USACE within 30 days of
permit issuance. NCDOT remains fuily responsible for the mitigation until the USACE has received this form, con�rming
that the Spansor tras accepted responsibility for providing the mitigation requirements iisted herein.
� Signed copies of this document must be retained by the Permittee, Mitigation Sponsor, and in the USACE
administrative records for both the permit and the Bank/ILF Instrument. It is the Permittee's responsibility to ensure
that the USACE Project Manager (address below) is provided with a signed copy of this form.
� If changes are proposed to the type, amount, or location of mitigation after this form has been signed and returned to
, the USACE, the Sponsor must obtain case-6y-case approval from the USACE Project Manager and/or North Carolina
Interagenry Review Team {NCIRT). If approved, higher mitigation ratios may be applied, as per current District
guidance and a new version of this form must be completed and included in the USACE administrative records for both
the permit and the Bank/ILF Instrument.
Comments/Additional Conditions:
This form is not valid unless signed below by the USACE Project Manager and by the Mitigation Sponsor on Page 1. O»ce
signed, the Spvnso� should provide copies of this form along with an updated bank ledger [o: 1J the Permittee, 2J the
USACE Project Manager ot the address below, and 3J the Wilmington District Mitigotion O�ce, Attn: Fodd Tugwell,
11405 Falls of Neuse Roard, Wake Forest, NC 27387 (email: [e-mail]!). Questions regarding this form
or any of the perrr►it conditions may be directed to the USACE Project Manager below.
USACE Projeci Manager_ Steve Kichefski
USACE Field OfFice: Asheville Regulatory Fieid O�ce
US Army Corps of Engineers
151 Patton Avenue, Room 208
Asheville, North Carolina 28801-5006
Email: [e-mail]
USACE Project Manager Sign�ture
October 16. 2015
Date of 5ignature
Current Wifmington District mitigation guidance, including information on mitigation ratios, functional assessments, and
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings) is
available at http://ribits.usace.armv.mil.
Page 2 of 2 '
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