NCC220307_FRO Submitted_20220114

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. MEF Operations Center (P1800)
1. Project Name
2. Location of land -disturbing activity: County OrlSIOW City or Township Camp Lejeune
Highway/Street Parachute Tower Road Latitude 34 40 43 Longitude 77 20 1
3. Approximate date land -disturbing activity will commence: 1 /01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Federal -Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 33
6. Amount of fee enclosed: $ 3,300 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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] Cell # 239-209-6259 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Commanding General, MCB Camp Lejeune 910-451-2212 910-451-2927
10.
Name
1005 Michael Road
Current Mailing Address
Camp Lejeune, NC 28547
city
Telephone
Same
Current Street Address
Same
State Zip City
Deed Book No. N/A Page No. N/A
Fax Number
State
Zip
Provide a copy of the most current deed.
Part B.
1. Company(les) 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 or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Commanding General, MCB Camp Lejeune
Name
1005 Michael Road
Current Mailing Address
Camp Lejeune, NC 28547
City
State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State
Fax Number 910-451-2927
Zip

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 E-mail Address
Current Mailing Address
City
Telephone
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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 MCB Camp Lejeune, Public Works Division
Type or print name Title or Authority
I III q rZl
Signature Date
a Notary Public of the County of
8
State of North Carolina, hereby certify that cc appeared
personally before me this day and being duly sworn acknowledged fhat the above form was
executed by him.
Witness my hand and notarial seal, this �,--7, day of �WILVN42�, 20 }
s j°USL1G s My commission expiresp
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