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HomeMy WebLinkAbout20050240 Ver 3_CAMA Application_20240628DIVISION OF COASTAL MANAGEMENT Fnviranmenra! FIELD INVESTIGATION REPORT QG<)Ilty 1. APPLICANT'S NAME: Dolores Angel 2. LOCATION OF PROJECT SITE: 2541 Middle Sound Loop Rd Wilmington, NC 28411 Longitude:-77.78638 Latitude: 34.24898 3. INVESTIGATION TYPE: 4. INVESTIGATIVE PROCEDURE: Date of Visit Purpose of Visit Applicant Present? 4/26/2024 application materials had been received No 5. PROCESSING PROCEDURE - Application Received Application Complete I Regional Office 5/15/2024 5/15/2024 1 DCM - Wilmington Regional Office 6. SITE DESCRIPTION: (A) Local Land Use Plan: NEW HANOVER, New Hanover County Land Classification from LUP: Land Classification From LUPs (B) AEC(s) Involved: Estuarine and Ocean System, Public Trust Areas, Estuarine Waters (C) Water Dependent: Yes (D) Intended Use: Private/Community (E) Wastewater Treatment: Existing: N/A Planned: N/A (F) Type of Structures: Existing: Piers (Ocean and Estuarine) and Docking Facilities, Boat slips, Floating structure, Pier or dock Planned: Piers (Ocean and Estuarine) and Docking Facilities, Boat lift (G) Estimated Annual Rate of Erosion: Erosion Information Source: Annual Erosion Source 7. HABITAT DESCRIPTION: DREDGED (ft) FILLED (ft) OTHER (ft) A Open Water 320 CW's above NHW C CW's below NHW Shallow Bottom High Ground Non -Coastal WL (E) Total Area Disturbed: 320 W (F) Primary Nursery Area: No (G) Water Classification: ORW: Outstanding Resource Waters; SA: Market Shellfishing, Tidal Salt Water Open to Shellfishing: No Field Investigation Report: Dolores Angel DCM Minor Modification Page I 8. PROJECT SUMMARY: The permittee is requesting approval to modify the existing single docking facility by installing two (2) lifts at the existing six (6) slip docking facility. The permittee does not request an increase in the total number of previously authorized slips. The existing docking facility is located adjacent to the AIWW/Middle Sound and Howe Creek, in Wilmington, New Hanover County. 9. NARRATIVE DESCRIPTION: Debbie Wilson, acting as agent for Angel Point Wilmington, LLC., has submitted a request to modify CAMA Major Permit No. 47-20, which was issued on April 21, 2020 to Queens Point, LLC., and expired on December 31, 2023. The permit was then renewed and transferred to Angel Point Wilmington, LLC. on December 19, 2023 and is due to expire on December 31, 2028. 10. PROJECT DESCRIPTION: The permittee is requesting approval to modify the existing single docking facility by installing two (2) lifts at the existing six (6) slip docking facility. The permittee does not request an increase in the total number of previously authorized slips. The existing docking facility is located adjacent to the AIWW/Middle Sound and Howe Creek, in Wilmington, New Hanover County. The area in which the docking facility is located is NOT Primary Nursery Area (PNA). The original permit (LAMA Major Permit No. 47-20) authorized the excavation of a 60' long x 160' wide boat basin to -4.0' at MLW that incorporated the entirety of the floating dock. The permittee is requesting authorization to install a new approximately 8' long x 8' wide open jet ski lift on the landward side of the southern end of the existing floating dock. The jet ski lift is proposed to be installed within an existing slip. The permittee is also requesting authorization to install a new approximately 16' long x 16' wide boat lift on the waterward side of the southern end of the floating dock. The proposed 16' x 16' boat lift on the waterward side of the floating dock would not exceed the 1/4 width of the waterbody nor would it impede navigation in the main channel. The installation of the 16' x 16' boat lift pilings would result in the expansion of the existing footprint of the docking facility. The permittee also proposes to re -deck the existing 10' x 100' floating dock. This would not result in a change of dimensions to the existing floating dock. 11. ANTICIPATED IMPACTS: The total slip count for the proposed modification to the existing docking facility would be a total of six (6) slips, the same as what was originally permitted by State Permit No. 47-20. The proposed 16' x 16' boat lift on the waterward side of the floating dock would not exceed the 1/4 width of the waterbody nor would it impede navigation in the main channel. Based on the information provided, regarding the minor modification request (plans and documents), there does not appear to be any impacts to any wetlands, and the size/footprint of the development plan would remain consistent with DCM's Rules concerning the Estuarine Shoreline and Public Trust AECs. Field Investigation Report: Dolores Angel DCM Minor Modification Page 12 At this time, this office has no objection(s) to this minor modification request. The applicant has submitted a check (No. 862) in the amount of $100 to cover the processing fee. Name: Kelsey Beachman Date: 05-30-2024 Office: DCM - Wilmington Regional Office Field Investigation Report: Dolores Angel DCM Minor Modification Page 13 Permit Application Report Application ID Application Type Submitted App Complete Deadline Decision Expiration PA-1411 DCM Major Permit Primary Applicant Information Applicant Type Title Business Name Name Email Business Phone Mobile Phone Individual Mrs. Dolores Angel loriangeldallas@gmail.com 2032418444 203-241- 8444 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 541 Middle Found Loop Road Wilmington NC 28411 2300 Wolf Street Dallas TX 75201 Additional Applicant Information Applicant Type Title Business Name Name Email Business Phone Mobile Phone Individual Mrs. Dolores Angel loriangeldallas@gmail.com 2032418444 203-241- 8444 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip 541 Middle Found Loop Road Wilmington NC 28411 2300 Wolf Street Dallas TX 75201 Registered Agent Information Agent Type Title Business Name Name Email Business Phone Mobile Phone Individual Ms. Debbie Wilson debbiew75@charter.net 910-612-0402 910-612-0402 Physical Address Mailing Address Street 1 City State Zip Street 1 City State Zip P. O. Box 16275 Wilmington North Carolina 28408 4828 Carolina Beach Rd Wilmington NC 28412- 2306 Project Information Project Name Project Type Disturbed Land Area (Scl Ft/Acres) 2541 Middle Sound Loop Rd Private/Community 320 Sq. Ft. / 0.01 Acres Is proposed project located in national registered historic district or national register listed/eligible: False List of previous state or federal permits for work on project tract: CAMA Major Permit #47-20 issued to Queens Point, LLC on 4/21/20 and Transferred to Angel Point Wilmington, LLC on 12/19/23. Project Location Information Address County River Basin Subdivision County Parcel ID Latitude Longitude 2541 Middle Sound Loop Rd Wilmington, NC 28411 New Hanover R05200-002-012-001 34.24898 -77.78638 Project Discharges to State Waters Discharge Type Surface Runoff Sanitary Wastewater Industry/Commercial Effluent Vessel I Wash Down Residential Other Wastewater/Stormwater Discharged Into Wetland? Discharge Same Salinity as Receiving Waters Is There Any Mitigation Proposed False False False Detailed Description of the Existing Development Located on the Property Existing Man -Made Features: House, garage, driveway, bulkhead, private docking facility, decks. Existing Land Uses: IReSI Uen lldI Existing Wastewater Treatment/Disposal: Solid Waste/Fish Offal/Trash Disposal: Use and Daily Operations of the Project When Complete Proposed Development Purpose: Private residential docking facility Buildings/Facilities/Units/Structures: jig taL, Ly Use & Daily Operations: Private residential docking facility Construction Methodology & Equipment: Typical marine construction with barge mounted pile driver Development Activities Narrative Specifics: Minor modification request to their existing CAMA Major Permit #47-20 for the complete redecking (no expansion) of the existing 10' x 100' floating dock and the installation of 2 new boatlifts (1 @ 8' x 8' & 1 @ 16' x 16') within existing slips at the 6-slip private residential docking facility. CAMA Major Permit #47-20 was originally issued to Queens Point, LLC on April 21, 2020, and was Transferred/Renewed to Angel Point Wilmington, LLC on December 19, 2023 and is due to expire on December 31, 2028. Also propose to re -deck the existing 10' x 100' floating dock. Application Narrative: As acting agent for Steve Angel (Angel Point Wilmington, LLC) who owns 2541 Middle Sound Loop Road, adjacent to the AIWW/Middle Sound and Howe Creek, New Hanover County, in Wilmington, NC, I am submitting the enclosed minor modification request to their existing CAMA Major Permit #47-20 for the complete redecking (no expansion) of the existing 10' x 100' floating dock and the installation of 2 new boatlifts within existing slips at the 6-slip private residential docking facility. CAMA Major Permit #47-20 was originally issued to Queens Point, LLC on April 21, 2020, and was Transferred/Renewed to Angel Point Wilmington, LLC on December 19, 2023 and is due to expire on December 31, 2028. As proposed, a new 8' x 8' jet ski lift will be installed on the landward side of the southern end of the floating dock (within slip #5) and a new 16' x 16' boatlift on the waterward side of the southern end of the floating dock (within slip #1) as shown on the attached site plan. It should be noted that the proposed boatlifts will be located within the currently authorized dredge footprint (approved Major Permit #47-20 dredge footprint site plan is attached). The proposed boatlifts will not encroach into the adjacent 15' Riparian Corridors of the adjacent property owners and existing water depths in the area of the boatlifts range from approximately-1%' to -4' at normal low water. The docking facility will continue to accommodate a total of 6 vessels. Please feel free to contact me if you need any additional information or have any questions. Boat Ramp Development Activity Included: False Shoreline Stabilization Development Activity Included: False Living Shoreline Development Activity Included: False Piers & Docking Facilities Development Activity Included: True Docking Facilities Details Facility Use # of Tie Pilings Existing Slips New Slips Private/Community 0 6 0 Piers & Docking Facility Structures Structure Type Length Width Quantity Boatlift 8 8 1 Boatlift 16 16 1 Freestanding Moorings & Buoys Associated With This Docking Facility Structures Consistent With Water Use Plan Existing Freestanding Moorings & Buoys Slips New Freestanding Moorings & Buoys Slips False Buoy Details: Moorings & Buoys Details Mooring or Buoy Distance From Shoreline I Arc of Swing Water Depth Excavation Development Activity Included: False Bridges & Culverts Development Activity Included: False Oceanfront Erosion Control Development Activity Included: False Temporary Structures Development Activity Included: False Utility Crossings Development Activity Included: False Freestanding Moorings, Buoys & Bird Nesting Poles Development Activity Included: False Log Removal/Marine Debris Development Activity Included: Yes/No Navigational Aids Development Activity Included: False Other Fill Below Water Level Development Activity Included: False Stormwater Structures Development Activity Included: False "Upland Development" Development Activity Included: False Energy Facilities Development Activity Included: False Aquaculture Development Activity Included: False Submerged Lands Mining Development Activity Included: False General Development Activity Details Required General Development Activity Questions These questions are applicable if 1 of the following development activities are included in the project (Boat Ramps, Freestanding Moorings, Buoys & Bird Nesting Poles, Piers & Docking Facilities, Temporary Structures, Living Shorelines, Shoreline Stabilization Submerged Lands Mining) Boat Type(s) Typical Boat Length Other Boat Type (Describe) Open runabout; Personal water craft 26 Adj Riparian Property Line #1 (Proximity of Adj Riparian Property Line #2 (Proximity of Adj Riparian Property Line #3 (Proximity of Structure Nearest to Property Line) Structure Nearest to Property Line) Structure Nearest to Property Line) 107 1268 Width of Water Body Water Depth @ Waterward End of Water Depth @ Most Landward Water Depth @ Most Waterward Structure (NLW or NWL) Boat Slip (NLW or NWL) Boat Slip (NLW or NWL) 224 -4 1 -1.5 -4 Navigational Number of Number of Day I Min Distance of Each Aid Placed Max Distance of Each Aid Placed Aids Required BuoV Markers Beyond Shoreline Beyond Shoreline False Marina Development Activity Details Required Permit Class TRANSFER/ RENEWAL STATE OF NORTH CAROLINA Department of Environmental Quality and Coastal Resources Commission JJ Crmtt for X Major Development in an Area of Environmental Concern pursuant to NCGS 113A-11 S X Excavation and/or filling pursuant to NCGS 113-229 Issued to Angel Point Wilmington, LLC 2300 Wolf Street Unit 17A Dallas TX 75201 Permit Number 47-20 Authorizing development in New Hanover County at ad'. to Howe Creek and the AlWW at 2541 Middle Sound Loo Rd., in Wilmington , as requested in the permittee's application dated 12/12/19 MP-1 2 and 3/10/20(MP-4),including attached workplan drawings(5),all dated "Revised 12/11/19". This permit, issued on December 19, 2023 , is subject to compliance with the application (where consistent with the permit), all applicable regulations, special conditions and notes set forth below. Any violation of these terms may be subject to fines, imprisonment or civil action; or may cause the permit to be null and void. Maintenance Excavation 1) In order to protect juvenile shrimp and finfish populations, no excavation or filling shall be permitted between April I and September 30 of any year without the prior approval of the Division of Coastal Management, in consultation with appropriate resource agencies. 2) No excavation shall take place outside of the area indicated on the workplan drawings. 3) Excavation shall not exceed-4 feet below the mean low water level. In no case shall the depth of excavation exceed the depth of connecting waters. (See attached sheets for Additional Conditions) This permit action may be appealed by the permittee or other qualified persons within twenty (20) days of the issuing date. This permit must be accessible on -site to Department personnel when the project is inspected for compliance. Any maintenance work or project modification not covered hereunder requires further Division approval. All work must cease when the permit expires on December 31, 2025 In issuing this permit, the state of North Carolina agrees that your project is consistent with the North Carolina Coastal Signed by the authority of the Secretary of DEQ and the Chair of the Coastal Resources Commission. Braxton C. Davis, Director Division of Coastal Management This,Nmit and its conditions a hereby accepted. Signature of Permittee Angel Point Wilmington, LLC ADDITIONAL CONDITIONS Permit No. 47-20 Page 2 of 3 4) The temporary placement or double handling of excavated or fill materials within waters or vegetated wetlands is not authorized. 5) No excavated or fill material shall be placed at any time in any vegetated wetlands or surrounding waters outside of the alignment of the fill area indicated on the workplan drawings. 6) The authorized project is located within a primary nursery area (PNA). Therefore, in accordance with NCAC 15A:07H.0208 of the Rules of the Coastal Resources Commission, no new dredging or excavation within the PNA shall be permitted. Dredging in any manner, including "kicking" with boat propellers, is not authorized. This prohibition shall be applied and enforced throughout the entire existence of the permitted structure. 7) All mechanized equipment will be regularly inspected and maintained to prevent contamination of waters and wetlands from fuels, lubricants, hydraulic fluids, or other toxic materials. In the event of a spill of petroleum products or any other hazardous waste, the permittee shall immediately report it to the National Response Center at (800) 424-8802 and provisions of the North Carolina Oil Pollution and Hazardous Substances Control Act will be followed. Spoil Disposal 8) No spoil material shall be placed within 30 feet of the mean high water line. 9) All excavated materials shall be confined above mean high water and landward of regularly or irregularly flooded marsh behind adequate dikes or other retaining structures to prevent spillover of solids into any marsh or surrounding waters. 10) The spoil disposal area shall be inspected and approved by a representative of the Division of Coastal Management prior to the commencement of any dredging activities. Maintenance Clause 11) The Division of Coastal Management shall be notified in writing at least two (2) weeks in advance of any maintenance excavation work authorized by this permit, and such notification shall include: A. The number of the original permit. S. A statement that no dimensional changes are proposed. C. A copy of the original permit plans with cross -hatching indicating the area to be maintained, the area to be used for spoil disposal, and the estimated amount of material to be removed. The location, design and holding capacity of the spoil disposal site shall be approved by a representative of the Division prior to the initiation of any maintenance dredging activities. D. The date of map revision and the permittee's signature shown anew on the original plan. NavigationalAids 12) Unless specifically altered herein, this permit authorizes the installation of 12 day marker type navigational aids, all as expressly and specifically set forth in the attached permit application and workplan drawings. Angel Point Wilmington, ILC ADDITIONAL CONDITIONS Permit No. 47-20 Page 3 of 3 13) The navigational aids shall conform with any and all appropriate regulations governing such structures, including but not limited to marking and lighting requirements of the N.C. Wildlife Resources Commission and/or the U.S. Coast Guard. USACE Conditions 14) In order to further protect the endangered West Indian Manatee, Trichechus manatus, the applicant trust implement the U.S. Fish & Wildlife Service's Guidelines, and strictly adhere to all requirements therein. The guidelines can be found at http-//www.fws.gov/nc-es/mamrnal/manatee uidelines. df. 15) An "As -Built" survey of the dredged channel must be submitted within thirty (30) days of project completion to the U.S. Army Corp of Engineers Wilmington Regional Office, 69 Darlington Avenue, Wilmington, North Carolina 28403. General 16) Any necessary easements or similar legal instruments shall be obtained prior to the initiation of dredging activities. 17) This permit shall not be assigned, transferred, sold, or otherwise disposed of to a third parry without the written approval of the Division of Coastal Management, 18) The permittee shall maintain the authorized work in good condition and in conformance with the terms and conditions of this permit. The permittee is not relieved of this requirement if he or she abandons the permitted activity without having it transferred to a third party. 19) The permittee and/or his or her contractor shall meet with a representative of the Division prior to project initiation. NOTE, This permit does not eliminate the need to obtain any additional state, federal or local permits, approvals or authorizations that may be required. DOTE: The U.S. Army Corps of Engineers authorized the project by way of Programmatic General Permit 198000291 {Action ID SAW-2005-00435) reissued 4/21/20. NOTE: The N.C. Division of Water Resources authorized the proposed project by way of General Water Quality Certification 4175 and assigned the project DWR Project No. 2005-0240 Q. NOTE: Future development of the permittee's property may require a modification of this permit. Contact a representative of the Division at (910) 796-7215 prior to the commencement of any such activity for this determination. The permittee is further advised that many non -water dependent activities are not authorized within 30 feet of the mean high-water level. NOTE: An application processing fee of $200 was received by DCM for this project. Permit Class TRANSFER/ RENEWAL STATE OF NORTH CAROLINA Department of Environmental Quality and Coastal Resources Commission r M t for X Major Development in an Area of Environmental Concern pursuant to NCGS I I3A-118 X Excavation and/or filling pursuant to NCGS 113-229 Issued to Angel Point Wilmington, LLC, 2300 Wolf Street, Unit 17A, Dallas, TX 75201 Permit Number 47-20 Authorizing development in New Hanover County at adj. to Howe Creek and the AIWW. at 2541 Middle Sound Loop Rd., in Wilmington , as requested in the permittee's application dated 12/12/19 (MP-1,2) and 3/10/20 (MP-4), including attached workplan drawings (5), all dated "Revised 12/11/19". This permit, issued on December 19, 2023 , is subject to compliance with the application (where consistent with the permit), all applicable regulations, special conditions and notes set forth below. Any violation of these terms may be subject to fines, imprisonment or civil action; or may cause the permit to be null and void. Maintenance Excavation 1) In order to protect juvenile shrimp and finfish populations, no excavation or filling shall be permitted between April 1 and September 30 of any year without the prior approval of the Division of Coastal Management, in consultation with appropriate resource agencies. 2) No excavation shall take place outside of the area indicated on the workplan drawings. 3) Excavation shall not exceed -4 feet below the mean low water level. In no case shall the depth of excavation exceed the depth of connecting waters. (See attached sheets for Additional Conditions) This permit action may be appealed by the permittee or other qualified persons within twenty (20) days of the issuing date. This permit must be accessible on -site to Department personnel when the project is inspected for compliance. Any maintenance work or project modification not covered hereunder requires further Division approval. All work must cease when the permit expires on December 31, 2028 In issuing this permit, the State of North Carolina agrees that your project is consistent with the North Carolina Coastal Management Program. Signed by the authority of the Secretary of DEQ and the Chair of the Coastal Resources Commission. /14 4r'�� Braxton C. Davis, Director Division of Coastal Management This permit and its conditions are hereby accepted. Signature of Permittee Angel Point Wilmington, LLC Permit No. 47-20 Page 2 of 3 ADDITIONAL CONDITIONS 4) The temporary placement or double handling of excavated or fill materials within waters or vegetated wetlands is not authorized. 5) No excavated or fill material shall be placed at any time in any vegetated wetlands or surrounding waters outside of the alignment of the fill area indicated on the workplan drawings. 6) The authorized project is located within a primary nursery area (PNA). Therefore, in accordance with NCAC 15A:07H.0208 of the Rules of the Coastal Resources Commission, no new dredging or excavation within the PNA shall be permitted. Dredging in any manner, including "kicking" with boat propellers, is not authorized. This prohibition shall be applied and enforced throughout the entire existence of the permitted structure. 7) All mechanized equipment will be regularly inspected and maintained to prevent contamination of waters and wetlands from fuels, lubricants, hydraulic fluids, or other toxic materials. In the event of a spill of petroleum products or any other hazardous waste, the permittee shall immediately report it to the National Response Center at (800) 424-8802 and provisions of the North Carolina Oil Pollution and Hazardous Substances Control Act will be followed. Spoil Disposal 8) No spoil material shall be placed within 30 feet of the mean high water line. 9) All excavated materials shall be confined above mean high water and landward of regularly or irregularly flooded marsh behind adequate dikes or other retaining structures to prevent spillover of solids into any marsh or surrounding waters. 10) The spoil disposal area shall be inspected and approved by a representative of the Division of Coastal Management prior to the commencement of any dredging activities. Maintenance Clause 11) The Division of Coastal Management shall be notified in writing at least two (2) weeks in advance of any maintenance excavation work authorized by this permit, and such notification shall include: A. The number of the original permit. B. A statement that no dimensional changes are proposed. C. A copy of the original permit plans with cross -hatching indicating the area to be maintained, the area to be used for spoil disposal, and the estimated amount of material to be removed. The location, design and holding capacity of the spoil disposal site shall be approved by a representative of the Division prior to the initiation of any maintenance dredging activities. D. The date of map revision and the permittee's signature shown anew on the original plan. Navieational Aids 12) Unless specifically altered herein, this permit authorizes the installation of 12 day marker type navigational aids, all as expressly and specifically set forth in the attached permit application and workplan drawings. Angel Point Wilmington, LLC ADDITIONAL CONDITIONS Permit No. 47-20 Page 3 of 3 13) The navigational aids shall conform with any and all appropriate regulations governing such structures, including but not limited to marking and lighting requirements of the N.C. Wildlife Resources Commission and/or the U.S. Coast Guard. USACE Conditions 14) In order to further protect the endangered West Indian Manatee, Trichechus manatus, the applicant must implement the U.S. Fish & Wildlife Service's Guidelines, and strictly adhere to all requirements therein. The guidelines can be found athttp:''�N,�N-,N,.fws.gov/nc-eslmai-nmal./i-nanatee «Liidelines.pdf. 15) An "As -Built' survey of the dredged channel must be submitted within thirty (30) days of project completion to the U.S. Army Corp of Engineers Wilmington Regional Office, 69 Darlington Avenue, Wilmington, North Carolina 28403. General 16) Any necessary easements or similar legal instruments shall be obtained prior to the initiation of dredging activities. 17) This permit shall not be assigned, transferred, sold, or otherwise disposed of to a third party without the written approval of the Division of Coastal Management. 18) The permittee shall maintain the authorized work in good condition and in conformance with the terms and conditions of this permit. The permittee is not relieved of this requirement if he or she abandons the permitted activity without having it transferred to a third party. 19) The permittee and/or his or her contractor shall meet with a representative of the Division prior to project initiation. NOTE: This permit does not eliminate the need to obtain any additional state, federal or local permits, approvals or authorizations that may be required. NOTE: The U.S. Army Corps of Engineers authorized the project by way of Programmatic General Permit 198000291 (Action ID SAW-2005-00435) reissued 4/21/20. NOTE: The N.C. Division of Water Resources authorized the proposed project by way of General Water Quality Certification 4175 and assigned the project DWR Project No. 2005-0240 v2. NOTE: Future development of the permittee's property may require a modification of this permit. Contact a representative of the Division at (910) 796-7215 prior to the commencement of any such activity for this determination. The permittee is further advised that many non -water dependent activities are not authorized within 30 feet of the mean high-water level. NOTE: An application processing fee of $200 was received by DCM for this project. i.: V +; i O N cc CO 00 Y r-I rI 0 1 4 }�. 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Box 1139 cfry siaie;zip+4 ' " " Wallace, NC 28466 ----------- ■ Complete items 1, 2, and 3. ■ Print your name and address on the reverse so that we can return the card to you. ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: JML Wilmington LLC c/o W. Clay Blue, Jr. P. O. Box 1139 Wallace, NC 28466 IIII1 1111 1111I I I (I II'I II I II (II 9590 9402 6666 1060 1803 07 2. Article Number (Transfer from service label) 7021 2720 0003 3113 6556 A. Signature X, 0 n ❑ Agent 1�1`�X- ❑Addressee B. Received by (Printed Name) C. Date of Delivery 17 y- y D. Is delivery address different from item 1? ❑ Yes If YES, enter delivery address below: ❑ No 3. 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