20150551 Ver 1_Receipt_20161221

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatory Miti Bion Resoonsibilfty Transfer Form
Permittee: Medtage Homes of the Carolinas Attn: Brian K+etchem Action ID: SAW -20.13-02263
Project Name. Deer Creek residential subdivision County:. Wake
Instructions to Permittee: The Permittee must provide a copy of this farm to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Division of Mitigation Services (NCDMS), who will thea sign the form to verify the
transfer of the mitigation responsibility. Once the Sponsor has signed this forth, it Is the Permittee's responsibility to
ensure that to the U.S. Army Corps of Engineers (USAGE) Project Manager identified on page two is in receipt of a signed
copy of this forme before conducting authorized Imparts, unless otherwise specified below.. If more than one mitigation
Sponsor wig be used to provide the mitigation associated with tate permit, or if the Impacts and/or the mitigation will occur
in more than one 8 -digit Hydrologic Unit Carie (HUC), 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 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 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 int Emuhlng lulu ion" !:11 t HUC and Basin*. 03030002, Cape Fear River Basin
Stream Impacts (linear feet) Wetland impacts acres
Warm Cool Cold Riparian Riverine Ri Arian Non-Riverine Mort -Riparian Coastal
-- _ _ 1 0.374
V more than one mitigation sponsor will be used for the permit, only Include impacts to be mitlitated by this sponsor
Com ensat Mi# ation Requirements: it -digit HUC and Basin: 03030002, Ca a Fear River Basin
Stream Mitigation credits Wetland Miti atian credits
Warm Coot Cold lti Arian Riverine Riparian Non-Riverine I Nan -Riparian Coastal
0.72
Mitigation Site Debited: N
(List the name of the bank to be debited. For umbrella ranks, also list the specific site. For NCDMS, list NCDMS. If the
NCDMS acceptance tetter identifies a specific site, also list the specific site to be debited).
Section to be completed by the Mittgation Wnsor
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 USAGE Permittee and Action
10 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 falls 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 of
,2- c,
Date of Signature
Page 1 of 2 Form Updated 23 November, 2011

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 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 USAGE 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 USAGE 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 USAGE 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 USAGE, the Sponsor must obtain case-by-case approval from the USAGE 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 neva version of this form must be completed and included in the USACE administrative records for both
the permit and the Bank/)LF Instrument.
Cory. men ts/Additional Conditions:
This form Is not valid unless signed below by the USAGE Project Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsor should provide copies of this form along with an updated flank ledger to: 1) the Permittee, 2) the
USACE Project Manager at the address below, and .3) the Wilmington District Mitigation Office, Attn: Todd iugwell,
1140.5 Falls of Neuse Road, Wake Forest, NC 27587 (email. [e-mail]). Questions regarding this form
or any of the permit conditions may be directed to the USAGE Project Manager below.
USACE Project Manager: lames Lastinger
VSACE Field q##ice: Raleigh Regulatbry Fleld 0ffice
US Army Corps of Engineers
3331 Heritage Trade Drive, Suite 10
Wake forest, North Carolina 27S87
Entail, rrtea,c lastingtrtrsa+ce.a�rrtiyif
July 13, 2016
Date of Signature
Current Wilmington District mitigation guidance, including information on mttigatlari ratios, functional assessments, and
mitigation bank location* and availability, and credit classifications (including stream temperature and Welland groupings) is
available at hill} /ribits usace arrnv toll.
Page 2 of 2
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