NCC223480_FRO Submitted_20221014

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
Project Name Central Maintenance Facility (North Carolina State Ports Authority)
2. Location of land -disturbing activity: County New Hanover City or Township City of Wilmington
Highway/Street Burnett Blvd. Latitude(decimal degrees) 34.197854 Long itude(decimaldegrees) 77.950890
Approximate date land -disturbing activity will commence: Upon Permit Reciept
4. Purpose of development (residential, commercial, industrial, institutional, etc.)
Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.83 acres
6. Amount of fee enclosed: $ 300 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Todd Walton E-mail Address [e-mail]
Phone: Office # 910.746.6460 Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
North Carolina State Port Authority
Name
P.O. Box 9002
Current Mailing Address
910.763.1621
Phone: Office # Mobile #
2202 Burnett Blvd.
Current Street Address
Wilmington
NC
28402
Wilmington
NC 28401
City
State
Zip
City
State Zip
10. Deed Book No.
1199
Page No.
821
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 orif the landowners) is
an individual(s), the names) of the owner(s) may be listed as the financially responsible party(ies).
North Carolina State Ports Authority
Company Name
P.O. Box 9002
Current Mailing Address
Wilmington NC 28402
City State Zip
Phone: Office # 910.763.1621
[e-mail]
E-mail Address
2202 Burnett Blvd.
Current Street Address
Wilmington NC 28401
City State Zip
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:
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State Zip
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.
Company DBA Name
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
Brian E. Clark
Type o p nt name
Signature
Executive Director
Title or Authority
-7II�iZ�
Date
U �Vy1Vj L , a Notary Public of the County of
State of North Carolina, hereby certify that bow� Lr' C `�%�'r �`--- _ 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 I� I + 'day of , 20
o ry
PATRICIA �,i1, FIAMRIC My commission expires
Notary Public, North Carolina
Brunswirk County
My Commission Expires
April 1 C., 2026