NCC217038_FRO Submitted_20211221

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
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 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 and/or
fax information unavailable, place N/A in the blank.)
Part A. NCIS Replacement Facility P1506
1. Project Name p y )
2. Location of land -disturbing activity: County OnsloW City or TownshipJacksonville
Highway/StreetJullan C Smith Latitude 34.6749277N Longitude-77.3616222W
3. Approximate date land -disturbing activity will commence: December 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.30
6. Amount of fee enclosed: $ 1 ,400 . 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 Talia Prendergast E-mail Address [e-mail]
Telephone [phone] x3242 cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Commanding General, MCB Camp Lejeune
Name
Telephone Fax Number
1005 Michael Road
Current Mailing Address
Current Street Address
Camp Lejeune, NC 28547
City State Zip
City State Zip
NA NA
10. Deed Book No. Page No.
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Commanding General, MCB Camp Lejeune
[e-mail]
Name
E-mail Address
1005 Michael Road
Current Mailing Address
Current Street Address
Camp Lejeune, NC 28547
City State Zip
City State Zip
Telephone [phone] ext. 3242
Fax Number [phone]

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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
TranSystems Corp.
Engineering Firm or other consultant
Brett M. Garvey
Individual contact person (type or print)
[e-mail]
E-mail Address
816-329-8648
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.
Talia Prendergast
Type or print name
Signature
MCB Camp Lejeune, Public Works Divison
Title or Authority
Date
a Notary Public of the County of
State of North Carolina, hereby certify that% appeared personally
before me this day and being duly sworn acknowledged that the above f rm was executed by him.
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