NCC230318_FRO Submitted_20230207

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this form
and an acceptable erosion and sedimentation control plan have been completed and approved by the Land
Quality Section, N.C. Department of Environmental Quality. Submit the completed form to the appropriate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Freedom Park Improvements Project
2
Location of land -disturbing activity: County Carteret
City or Township Beaufort
201 Freedom Park Road 34.716960-76.635020
Highway/Street Latltude(decimalaegrees) LongltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: Upon Received Permit
4. Purpose of development (residential, commercial, industrial, institutional, etc.): public and recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.93 acres
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Eugene FOXWorth E-mail Address [e-mail]
Phone: Office # 252-728-8450 Mobile # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Carteret County 252-728-8450 N/A
Name Phone: Office # Mobile #
302 Courthouse Square 302 Courthouse Square
Current Mailing Address Current Street Address
Beaufort, NC 28516 Beaufort, NC 28516
City State Zip City State Zip
10. Deed Book No. 363 Page No. 146 Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the namo(s) of the owner(s) may he listed as the financially responsible party(ies).
Carteret County
Company name
302 Courthouse Square
Current Mailing Address
Beaufort, NC 28516
[e-mail]
E-mail Address
302 Courthouse Square
Current Street Address
Beaufort, NC 28516
City State Zip City State Zip
Phone: Office # 252-728-8450 Mobile # N/A
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Eugene Foxworth
Name of Registered Agent
302 Courthouse Square
Current Mailing Address
Beaufort, NC 28516
City State Zip
Eugene. [e-mail]
E-mail Address
302 Courthouse Square
Current Street Address
Beaufort, NC 28516
City
Phone: Office # 252-728-8450 Mobile # NIA
Eugene Foxworth
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State zip
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath. (This form must be signed by the Financially Responsible Person if an individual(s)
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein,
Eugene Foxworth
Type or print name
Signat re
Assistant County Manager, Carteret County
Title or Authority
Date
GAP'', W. , a Notary Public of the County of ems °' "�
State of North Carolina, hereby certify that . 5 �*" e- appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of ����° , 24 ?-7 --
Seal
LORI R TURNER
NOTARY PUBLIC
Carteret County
North Carolfna
My Commission Expires May 18, 2026
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Notary /
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