20161150 Ver 1_signed MRT Form_20161221

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatorv Mitigation Responsibility Transfer Form
Permittee: NC DOT
Project Name: B-4950/hridges 171 and 172/South River
Action ID: SAW-2009-01691
County: Cumberland
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. 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 specifed below. If more than one mitigation Sponsor will be
used to provide the mitigation associated with the permit, or ifthe impacts and/or the mitigation will occur in more than one
8-digit Hydrologic Unit Code (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 Impacts Requiring Mitigation"
Stream Impacts (linear feet)
Warm Cool Cold
HUC
Wetland Impacts (
3n Riverine Riparian Non-Riverine
0.32
River Basin
Coastal
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
Stream Mitigation (credits)
Warm Cool Cold
HUC and Basin: 03030006, Cape Fear River Basin
Wetland MitiRation (credits)
an Riverine I Rinarian Non-Riverine
0.64
Coastal
Mitigation Site Debited: DMS
(List 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).
Section to be completed by tNe Mitigation Sponsar
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
ID 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 of Sponsor's Authorized
of Sponsor's Authorized
Date of
Page 1 of 2 Form Updated 23 November, 2015

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, though the Permittee remains
responsible for any other mitigation requirements stated in the permit conditions.
• Construction withinjurisdictional areas authorized bythe permit identified on page one ofthis 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 impads 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 USACE has received this form, confirming that the
Sponsor has accepted responsibility for providing the mitigation requirements listed herein.
o 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.
• 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 approvalfrom 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 Project Manager and by the Mitigation Sponsor on Page 1. Once
signed, the Sponsorshould provide copies of this form alonq with an updated bank ledger to:1) the Permittee, 2J the USACE
Project Manager at the address be%w, and 3J the Wilmington District Mitigation Office, Attn: Todd Tugwell, 11405 Falls
of Neuse Road, Wake Forest, NC27587 (email: [e-mail]). Questions regarding this form or any of the
permit conditions may be directed to the USACE Project Manager below.
USACE Project Manager: Liz Hair
USACE Field Office: Wilmington Regulatory Field Office
US Army Corps of Engineers
69 Darlington Avenue
W ilmi ngton, NC 28403
Email: [e-mail]
December 21, 2016
Date of Signature
Current Wilmington District mitigation guidance, including information on mitigation ratios, functiona) assessments, and
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings) is
available at http:/lribits.usace.armv.mil.
Page 2 of 2
The Wilmington District is committed to providingthe highest level of support to the public. To help us ensure we continue to do so, please complete the
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