SW6140505_Sediment Pollution Form_20140728

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM FE8 1 0 2015
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name RTI Motor Pool Expansion at Fort Bragg
2. Location of land -disturbing activity: County Cumberland City or Township Fort Bragg
Highway/Street Pratt Street Latitude 35.1591 Longitude-79.0146
3. Approximate date land -disturbing activity will commence: November 2012
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Motor Pool (Parking
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.33
6. Amount of fee enclosed: $ 130 + 500 . The Express Permitting application fee is a dual charge. The
normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express Permitting
supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee
is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are rounded up to the next
whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Nicholas S. Rightmyer, P E E-mail Address nrightmver(a)msconsultants com
Telephone [phone] Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Department of Defense
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State
Zip
City State
Zip
10. Deed Book No.
Page No.
Provide a copy of the most current
deed.
Part B.
1. Person(s) or firm(s) who are
financially
responsible for the land -disturbing activity
(Provide a
comprehensive list of all responsible
parties on an attached sheet):
North Carolina National Guard
toni.coatsOus.army.mil
Name
E-mail Address
1636 Gold Star Road
1636 Gold Star Road
Current Mailing Address
Current Street Address
Raleigh, NC 27607
Raleioh, NC 27607
City State
Zip
City State
Zip
Telephone [phone]
Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
State
E-mail Address
Current Street Address
City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
Address
Current Street Address
City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
ms consultants inc.
Engineering Firm or other consultant
Nick Riahtmver
Individual contact person (type or print)
nrightmverOmsconsultants. com
E-mail Address
252-519-2135 252-519-2137
Telephone Fax Number
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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
LTC Toni L. Coats
Type or print names
d • ��
Signature
Title or Authority
Date
-----------------------------------------------------------------------------------------------------------------------------------------------
I, 1 a Notary Public of the County of
State orth Carolina, hereby certify that T�`wl C4^�ac� appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this QC day of 20 i2
CMN
A DUNN Not ry
My commission