NCC222747_FRO Submitted_20220801

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or mo,e acres as covered by the Act before tn!s
form and an acceptable erosion and sedimentation cont£o p an 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 andi
or fax information unavailable place NA in the blank )
Part A. Hadnot Point Water Treatment Plant Replacement (P1043)
1. Project Name
2 Location of land -disturbing activity: County Onsiow City or Township MCB Camp Lejeune
Highway/Street Holcomb Boulevard Latitude 34.6657622 Longitude-77.349952
3 Approximate date land -disturbing activity will commence. April 1, 2022
4 Purpose of development (residential. commercial industr al, institutional. etc ) Federal Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 20 Acres
6 Amount of fee enclosed S 1300 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 S585)
7 Has an erosion and sed ment control plan been filed? Yes- No Enclosed X
8 Person to contact should erosion and sediment control issues arise d4mng land -disturbing activity
Name Heather Blackwell E-mail Address heather. [e-mail]
Telephone Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners) -
Commanding General MCB Camp Lejeune 910-451-2212 910-461-2927
Name
1005 Michael Road
Current Mailing Address
Camp Lejeune, NC 28547
City State
10. Deed Book No NIA
Telephone Fax Number
1005 Michael Road
Current Street Address
Camp Lejeune, NC 28547
Zip City
Page No NIA
State
Zip
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 ) Itthe company or firm is a sore propr+etorsh p.
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
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone [phone] Fax Number 910-451-2927

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 -
N/A
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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
N/A
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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
PWD Civil Engineer
Title or Authority
2A n" -L*74
Signature U Date
1, a Notary Public of the County of
State of North Carolina, hereby certify that _%L ` h 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 _day of 4J20 al
It �• °F,':� Notary
My commission expires_ o`%
'�''+..ti' Coin••'