20071962 Ver 1_Mitigation Information_20071003

MITIGATION REQUEST FORM.
TRI-PARTY MOA (NCDOT)
NCDENR
Revised 3/2212007
Fill in requested information, print out the form, sign and date, and either mail to EEP, 1652 Mail Service Center, Raleigh, NC 27699-1652, or
fax to 919-715-2219. Attachments are acceptable for clarification purposes.
Electronic submissions are permissable; however, an acceptance letter cannot be sent until the original signed form has been received.
NCDOT CONTACT INFORMATION REGULATORY CONTACT INFORMATION
Agency/Division NCDOT Highways USACE Office Regulatory Field Office
Branch PDEA-NEU USACE Contact Mr. Eric Alsmeyer
Mailing Address 1598 Mail Service Center Mailing Address 6508 Falls of the Neuse Rd, Ste 120
City, State, Zip Raleigh, NC 27699-1598 City, State, Zip Raleigh, NC 27615
Project Manager Deanna Riffey USACE Fax Number [phone]
Telephone Number NCDWQ Contact John Hennessy
E-Mail Address [e-mail] Mailing Address 1650 Mail Service Center
Supervisor Rachelle Beauregard City, State, Zip Raleigh, NC 27699-1650
Telephone Number NCDWQ Fax Number
PROJECT LOCATION INFORMATION AND IMPACTS
TIP Numbers B-4124
TIP Description BR 84 over the Tar River on SR 1141
nt Let Date 02/19/08
IT Highway Division Division 5
ies) Granville
ion s) Central Piedmont
Basins Tar-Pamlico
mina Units (8-di it) 03020201
Warm
i (feet) Cool
Cold
TOTAL
in Wetland Impact (acres)
arian Wetland Impact acres
I March Impact (acres)
Impact Zone 1 (square feet 1400
Zone 2 (square feet) 3260
y•
02c/c/
J
JTHER INFORMATION
1SACE Action ID Number (if known)
JCDWQ Project Number (if known)
JCDCM Project Number (if known)
IMPORTANT Signature of Applicant or Agent:
Check below if this request is a:
? New Mitigation Request
® Revision to a current accejRfi Date: I0?3?D 7
OCT 3 - 2w