20150596 Ver 1_DMS Letter_20160127

U.S. ARMY CORPS OF ENGINEERS
Wijrnirigton. District
Compensatory Mitigation ResponsibiliW Transfer Form.
Permittee: Sam Lockridge, Cleveland County Heath .DepartmentAden ID. SAW -2015-00736
Project Mame; Cleveland County Landfill County: Cleveland
instructions to Permittee: The Permittee must provide a copy of this form to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Division of Mitigation Services (NCDMS), who will then sign the form to verify the
transfer of the mitigation responsibility. Cance the Sponsor has signed this form, it the Permitteets responsibility to ensure
that tot -he U.S. Army Corps of Engineers (USACE) Project Manager identified tin page two is in receipt of a signed copy of this
form before conducting authorized impacts, unless otltei^w se specified below. if more than one mitigation Sponsor will be
used to provide the mitigation associatedwith 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 he attached to the permit, and the separate forms for each Sponsor
and/or HUC most be provided to the appropriate mitigation Sponsors.
Instructions to Sponsor: The Sponsor must verify that the mitigation 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 payrmnt 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 Impacts Requiring Mitigation* 8 -digit HUC and Basin: 03050105, Broad diver Basin
Stream Impacts (linear feet}
Wetland Impacts (acres)
warm
-1 Cold
Riparian Riverine
Riparian Non-Riverine
Non-RiparianCoastal
532
_32
it more tnan one mitigation sponsor will be used for the permit; only include impacts'to be mitigated by this sponsor.
Compensatory Mitigation Recuirements: 8-dieit Htir anri € nc;n• mnsninr nx s?r.,ar air;
Stream
Mitigation (credits) - — Wetland Mitigation (credits)
Warm
Cool Cold Riparian Riverine Riparian Non-Riverine Non -Riparian Coastal
53,
.32
Mitigation Site Debited: NCDMS
(i_ist the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDMS. if the NCDMS
acceptance letter identifies a specific site, also list the specific site to be debited). I
Section to be completed by the Mitigatioq 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 I 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
lD number shown. I also verify that released credits (and/or advance credits for NCDMS), 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' Wilmington District Engineer may pursue measures against the Sponsor .to
ensure compliance associated with the mitigation requirements.
Mitigation Sponsor Name:
Name
%. .,,
Date ofsianature _ -
Page 1 of 2 Form Updated 23 November, 2m

USACE Wilmington District
Compensatory Mitigation Responsibility Transfer Form, Page 2
Conditions for Transfer of Compensatory Mitigation Credit:
• Once this document has been signed by the Mitigation Sponsor and the USACE is in receipt of the signed form, the
Permittee is no longer responsible for providing the mitigation identified in this form, t! nugh the Permittee remains
responsible for any other mitigation requirements stated in the permit conditions.
• Constructdon 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�mitigatlon requirements listed herein. For authorized impacts conducted by the North
Carolina Department of Tmnsporta . tion (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. INCDOT remains fully responsible for the mitigation( until the USACE has received this form, confirming that the
Sponsor has accepted responsibility for providing the mitigation requirements listed herein.
• Signed copies of this document must be retained by the Perrnittee, mitigation Sponsor, and in the USACE administrative
records far both the perm , It and the Bank/lLF Instrument. It Is. the Permittee's responsibility to ensure Ihai 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-by-case approval from the USACE Project Manager and/or North Carolina
interagency 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 ProjeFct Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsor should provide copies ofthis form along with an updated bank ledger to: 1) the Permittee, 2) the USACE
project manager at the address below, and 3J the Wilmington DistrfCt mitigation Office, Attn: Todd Tvgwell, 11405 Falls
of t4euse Road, Wake Forest, NC27587 (email. tar ef tugwellousrce.anny.mil). Questions regarding this form or any of the
permit conditions may be directed to the USACE Project Manager below,
USACE Project Manager: William Elliott
USACE Field Office, Asheville Regulatory Field Office
US Army Corps of Engineers
IS 1 Patton Avenue, Room 208
-Asheville, North Carolina 28801-5006
Email- [e-mail]-miI
Der -ember 2L,P_
USACE Project Manager Signature Date of Signature
Current Wilmington District mitigation guidance, including information an mitigation ratios, functioral assessments, and
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings} is
available at http-/,,'ribits.usacearmy.mi,'.
Page 2 of 2
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