20160693 Ver 1_Receipt_20161221

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
ggMpAn8tg[XmIlIgIflon Resragas ns b_II l L i=orm
Permittee. t .. OEM 14mg Action irk: SAW-20IS-01484
Project marne: Care Chapel Rd. Form Main and water line bounty* Wake
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 (NCOMS), who will then sign the form 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 (HUp, multiple forms will be attached to the permit, and the separate forms
for each Sponsor and/or HUC must be provided to the appropriate mitigation Sponsors.
Instructions to sponsor. The Sponsor mint 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 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 USAGE Project
Manager, arra 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 ltrptstts and CompenszstM Mitigation Itequlre"Wats:
f3raaw'�ikAw�,
L-6. *......rtlmaLft s rinn:• kileft.Htle and Basic,-: 03030002. Cape Fear river Basin
i 'Ww
Stream impacts linear feet Wetland Impacts acres}
Warm Coot
Cold Riparian Riverine
iii areari Pion-Riverine I Non-RiparianCoastal
0.104
"If more than one mitigation sponsor will be used for the permit, onty include impacts to be mitigated by Lnis sponsur.
.».ws...r. sANis:Mte..r oru..dMeNtantc, *.dl** Nut and aasln. 030WW2. Carie Fear lover Basin
Stream mitigation credits Wetland Mitigation (credits
Warm
Cool Cold I Riparian Pliverine Riparian Non-Riverine
Non.RI araan Coastal
Mitigation Site Debited: N DM
(List the name of the bank to be debited. For umbrella banks, also list the specific site. For NCDMS, list NCDM,5, If the
MCDMS acceptance letter identifies a specific site, also list the specific site to be debited),.
Section to be completed by the Mitfptsdon Sponsor
Statement of Mitigation Liability AcMptanee. 1, 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
10 number shown. I also verify that released credits (and/or advance credits for NCOMS), as approved by the USACE, are
currently available ,at the mitigation site Identified alcove. Further, t 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.
Marne
9_1 ZZ 1 L
Date of Signature
Page 1 of 2 Form updated 23 November, 2015

USACE Wiimkigtan District
Compensatory Mitigation ReSgonsibilitY Transfer Form, Page 2
�V
conditions for Transfer of *empensatory Mitigation Credit:
rr Once this document has been signed by the Mitigation Sponsor and the USAGE is in receipt of the signed form, the
Permittee is no longer responsible for providing the mitigation identified in this form, though the Permittee remains
responsible for any other mitigation 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 fully responsible for the mitigation until the USAGE 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 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.
e if changes are proposed to the type, amount, or location of mitigation after this form has been signed and returned to
the USAGE, 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:
the USACE Project Manager and by the Mitigation Sponsor on Page 1. OrK
16
This form is not valid unless signed below by
signed, the Sponsor should provide copies of this form oiorag with an updated rank ledger to:.) the Permittee, 2) the
USACE Project Manager at the address below, and 3) the Wilmington District Mitigation office, Attn: Todd Toexgwell,
z....rotoart..�rcal. Ex.nrr!,.e+n�elife7uscrte.crrmy,r.�i!), Questions regarding this form
USACE Project Manager: James Lastinger
USACE Field Office: Raleigh Regulatory Field Office
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 105
Wake Forest, North Carolina 27587
Errrafi: jarrses.c.lastir�gercrsace.aC'r1" rnil
mate Of $tgnatrarry
smentsand
Current Wilmington District mitigation guidance, including information on mitigation ratios, functional asses,
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings) is
available at htto //ribits usacearmv.m'si.
Page 2 of 2
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