20140938 Ver 2_Mitigation Transfer Form_20180611

U.S. ARMY CORPS OF ENGINEERS
Wilmington District
Compensatorv Miti�ation Responsibilitv Transfer Form
Permittee: North Carolfna DepartmentofTransportation Actfon ID: SAW-2014-01666
Project Name: Bridge 162 on SR 1361 / WBS Element 17BP.14.R.126 County: Transylvania
Instructlons to Permittee: The Permittee must provide a copy of this form to the Mitigation Sponsor, either an approved
Mitigation Bank or the North Carolina Ecosystem Enhancement Program (NCEEP), who will then sign the form to verify the
transfer of the mitigation responslbili[y. 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 wi[h the permit, or if the impacts and/or the mitigation will occur
in more than one 8-digit Hydrologfc Unit Code (HUC), multiple forms will be at[ached to the permit, and the separo[e forms
for each Sponsor and/or HUC must be provided [o the appropriate mitigation Sponsors.
Instructions to Sponsar: 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 responsi6ility for the identified mi[igation, 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 [he 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 mmply
with all reporting requirements established in their authorizing instrument.
Permitted Impacts and Compensatory Mitigation Requireme�ts:
Permitted Imaacts Reauirine Mitieatlon• 8-dieit HUC and Basin:
Stream Impacts Qinear feet)
Warm Cool Cold
*If more than one mitigation sponsor
Com
Stream Mitigation (credits)
Warm Cool Cold
74
permit, only include impacts to be mitigated by this sponsor.
it HUC and Basin: 06010105, French 8road
Wetland Mitigation (credits)
Riverine Rioarian Non-Riverine Non-R
MitigationSlteDe6ited: NCEEP
(List the name of the bank to he debited. For umbrella banks, also list the specific site. For NCEEP, list NCEEP. If the NCEEP
acceptance letter identifies a specific site, also list the specific site to be debited).
Section ta be campleted by the Mitlgation Sponsor
Statement of Mitigation Liabllity Acceptance: I, the undersigned, verify [hat I am authorized to approve mitigation
trensactions 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 Permi[tee and Action
ID number shown. I also verify that released credits (and/or advance credits for NCEEP), as approved by the USACE, are
currently available at the mitigation site icientified 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 mi[igation requirements.
Mitigation Sponsor
Sponsor's �
��
of Sponsor's Authorized Representative Date
Page 1 of 2 Form Updated 12 September, 2014

USACE Wilmington District
Compensatory Mitigation Responsibility Transfer Form, Page 2
Conditions for Trensfer of Compensatory Mitigation Gredit .
• 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 wi[hin 30 days of
permit issuance. NCDOT remains fully responsible for the mitigation until the USACE has recelved this form, confirming
that the Sponsor has accep[ed responsibility for providing the mitigation requirements listed herein.
• Signed copies of this document must be retained by the Permit[ee, 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 aker this form has been signed and returned [o
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 Conditfons:
This form is not valid unless signed below by the USACE Project Manager and hy the Mitigation Sponsor on Page 1. Once
signed, the Sponsor should provide copies of fhis form along with an updated bank ledger to: 1) ihe Perm7tiee, 2) the
USACE ProJec[ Manager at the address below, and 3J fhe Wilmingtan Dfstrlct Mitlgatlon OJ/ice, Attn: Todd Tugwell,
11405 Fdlls of Neuse Road, Woke Farest NC 27587 (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: Lori Beckwith
USACE Field Office: Asheville Regulatory Field Office
US Army Corps of Engineers
151 Pat[on Avenue, Room 208
Asheville, North Carolina 28801-5006
E m a il: lo retta.a. beckwith @ u sace.army.m il
Digitally signed by
BECKWITH.LORETT o;; <`",;TMo`°�S �o e"�m'e�, o�' 000,
A.ANN.1173452264 �n=BECKWRN. OflETfA.ANN.11]34512G4
Lori Beckwith Date:2014d0.0I16:41:48-04'00' OCCOI7ff 7 ZOSA
USACE Project Manager Signature . Date of Stgnature
Current Wilmington District mitigation guidance, including information on mitigation ratios, functional assessments, and
mitigation bank location and availability, and credit classifications (including sVeam temperature and wetland groupings) is
available at http://ribits.usace.armv.mil.
Page 2 of 2
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Customer Satisfaction Survey located at our website at h��ePi., �_latorv.usacesurvev.mn�/ ro comple[e the survey online.