NCC221513_FRO Submitted_20220420

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name Camp Johnson Ambulatory Care Clinic Replacement (P4639)
2. Location of land -disturbing activity: County OnsloW City or Township Camp Lejuene
Montford Landing Road 34°44'06.2"N n`24!34.2"W
Highway/Street Latitude�a�;me, degrees) LOngitude�a�me� degrees)
1 Approximate date land -disturbing activity will commence: April 10, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc-: MEDICAL FACILITY
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.19 ACRES
6. Amount of fee enclosed $1,750 The Express Permitting application fee is a dual charge
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑X No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Emerson Reich E-mail Address [e-mail]
Phone: Office # 910-850-2841 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Commanding General MCB Camp Lejeune 910 451-2212
Name
1005 Michael Road
Current Mailing Address
Camp Lejeune, NC 28547
City State
Phone: Office #
1005 Micheal Road
Current Street Address
Zip City
State
Mobile #
Zip
10. Deed Book No. NA Page No. NA 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Commanding General, MCB Camp Lejeune talia.barracoOusmc.mil
Company Name E-mail Address
1005 Michael Rd
Current Mailing Address Current Street Address
Camp Lejeune NC 28547
City State Zip City State Zip
Phone: Office # Mobile #
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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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
NA
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip Cfty State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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.
NA
Company DBA Name
(d) If 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:
RQ Construction, LLC
Engineering firm or other consultant
Thomas L. Fitzgerald, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
434 665 2187 434 665 2187
Phone: Office # Mobile #
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.
Talia Prendergast
Type or print name
Signature
MCBCL Public Works Division Civil Design Branch
Title or Authority
Q3111/2.7—
Date
a Notary Public of the County of ny�
State of North Carolina, hereby certify that �ja. _ 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 A day of 20 Q--
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