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IV Application for Withdrawal of Wetland Credits V—Sd from the Minnesota Wetland Bank If the layout of this form looks incorrect, click on View, Edit Document, then save to your computer. 'relit User This space is for BWSR use only. To be completed by the person or entity proposing to use the wetland credits. Debit Date: Name: Mike Ericson(Administrator) Organization (if applicable): City of Centerville Street Address: 1880 Main Street City, State,Zip: Centerville, MN 55038 Phone: 651-429-3232 E-Mail Address*: medcson@centervillemn.com 2. Wetland Impact Information To be completed for the project with wetland impacts that this withdrawal is intended to replace. Project Name: Centerville Regional Trail Link Wetland Impact Size(acres): 0.0397 County of Impact: Anoka Replacement Ratio: 2:1 Impact Major Watershed #: 20 Total Replacement Required (acres): 0.0793 Impact Bank Service Area: 7 U.S. Army Corps Permit#(if applicable): #2009-00383-TJF **Sec. 23 Twp. 31 Rge. 22 LGU File#(if applicable): #09-017 )jects with multiple impact locations should use the most central location in relation to the project as a whole. Comments: Credits purchased with this application are for impacts beyond original permitted impacts already mitigated. By signature below,the proposed user of credits attests that he/she owns or has purchased the credits identified in this application and has received approval from the applicable regulatory authority(ies). Credit User Signature: Date: 3. Regulatory Approval/Authorization By signature below,the identified agency and authorized representative hereby certify that they have: a)verified that the subject wetland credits are deposited in the account of the owner/seller, b)approved a wetland replacement plan or similar agreement under their jurisdiction,and c)approve the proposed use of the wetland bank credits described herein. WCA LGU/Agency: Rice Creek Watershed District E-mail address*: ntomczik@dcecreek.org LGU Representative: Nick Tomczik Signature: Date: ------------------------------------------------------------------------------- (for NRCS, USACE, etc. if applicable) Agency Name/Location: E-mail address*: Representative: Signature: Date: �firmation will be e-mailed to user,seller,and regulatory representative when the transaction is complete. If you would like others notified, e-mail addresses here. mark.statz@stantec.com Rev 6/9/2014 BWSR Application for Withdrawal of Wetland Credits Form Page 1 of 2 C•\Users\tbender\AppData\Local\Microsoft\Windows\Temporary Internet Files42t ent.0utlook\9N1G4319\application_for_withdrawal_of_credrts form 11 25.14.docx