20170864 Ver 1_MRTForm R-5752 signed_20170906

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatorv Miti�ation Responsibilitv Transfer Form
Permittee: NC DOT/Division 6/Mr. Greg Burns, PE
Project Name: R-5752/US 74 and SR 2220 Interchange
Action ID: SAW-2016-00716
County: Robeson
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 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 (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* 8-digit HUC and Basin: 03040203, Lumber River Basin
Stream Impacts (linear feet
Warm Cool
350
Wetland Im
Cold Riparian Riverine Riparian Non-Riverine Non-Riparian Coastal
3.39
*If more than one mitigation sponsor will be used for the permit, only include impacts to be mitigated by this sponsor.
ipensatory Mitigation Requirements:
Stream Mitigation (credits)
Warm Cool Cold
350
8-dieit HUC and Basin
Wetland M
Lumber River Basin
ion (credits)
Riparian Riverine Riparian Non-Riverine Non-Riparian Coastal
3.39
Mitigation Site Debited: NC 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 the Mitigation Sponsor
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:
Name of Sponsor's Authorized Representative:
Signature of Sponsor's Authorized Representative Date of Signature
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 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 USACE 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.
• 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 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:
1.34 acres riparian wetlands at 2:1 for fill/excavation impacts totals 2.68 acre credit required
0.71 acres riparian wetlands at 1:1 for mechanized land clearing totals 0.71 acre credit required
3501inear feet of warm water stream at 1:1 for fill/pipe impacts totals 3501inear feet credit required
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 along with an updated bank ledger to:1J the Permittee, 2J the USACE
Project Manager at the address below, 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
USACE Field Office:
Email:
Page 2 of 2
Liz Hair
Wilmington Regulatory Field Office
US Army Corps of Engineers
69 Darlington Avenue
Wilmington, NC 28403
[e-mail]
USACE Project Manager Signature
September 6, 2017
Date of Signature
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U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Current Wilmington District mitigation guidance, including information on mitigation ratios, functional assessments, and
mitigation bank location and availability, and credit classifications (including stream temperature and wetland groupings) is
available at http://ribits.usace.armv.mil.
Page 1 of 2 Form Updated 23 November, 2015