NCC223420_FRO Submitted_20221013

FINANCIAL RESPONSIBILITY/OWNERSHIP 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 N/A in the blank.)
Part A. MOTSU Blast Berm Design
1. Project Name g
2
3.
4.
5.
6.
Location of land -disturbing activity: County Brunswick
City or Township Smithville Township
Highway/Street N/A Latitude 34.010289 Longitude -77.973774
Approximate date land -disturbing activity will commence: January 2, 2023
Purpose of development (residential, commercial, industrial, institutional, etc.): Operational/US Army
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.8
Amount of fee enclosed: $ 800.00 . 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 Adrienne Rogers E-mail Address [e-mail]
�7
Telephone [phone]
Cell# [phone] Fax# N/A
Landowner(s) of Record (attach accompanied page to list additional owners):
United States of America [phone]
Name Telephone
6280 Sunny Point Rd 6280 Sunny Point Rd
Current Mailing Address
Southport, NC 28461
City
10. Deed Book No. 189
Current Street Address
Southport, NC 28461
State Zip City
Page No. 513
State
N/A
Fax Number
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.) If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Military Ocean Terminal Sunny Point [e-mail]
Name
6280 Sunny Point Rd
Current Mailing Address
Southport, NC 28460
City
State Zip
Telephone [phone]
E-mail Address
6280 Sunny Point Rd
Current Street Address
Southport, NC 28460
City State Zip
Fax Number N/A

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 N/A
Name E-mail Address
N/A N/A
Current Mailing Address
N/A
City
Telephone N/A
Current Street Address
N/A
State Zip City State Zip
Fax Number N/A
(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 N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Telephone N/A Fax Number N/A
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.
Adrienne Rogers Environmental Compliance Manager
Type or pri
Signature
12
Title or Authority
23 AunL s. - 20 2`2
Date
I, j&4G4C &4LM* ! a Notary Public of the County of "RV'k* LJ 1C�
State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. AV my hand and notarial seal, this 23 day of 20 2 2
M MgNH
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Seal
My commission expires
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