NCC240568_FRO Submitted_20240312

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 N/A in the blank.)
Part A.
1. Project Name North Carolina State Ports Authority- Areas F West and H Yard Improvements
`If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County New Hanover City or Township Wilmington
Highway/Street1 Shipyard BLVD Latltude(decimaidegrees)34.1969 77.9505
Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: Upon receipt of permit
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.85 acres
6. Amount of fee enclosed: $ 1 ,400.00 . 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 ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Todd Walton E-mail [e-mail]
Phone: Office# 910-746-6460 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NC State Ports Authority 910-763-1621
Name Phone: Office# Mobile#
2202 Burnett Blvd. 2202 Burnett Blvd.
Current Mailing Address Current Street Address
Wilmington, NC 28402 Wilmington, NC 28402
City State Zip City State Zip
10. Deed Book No.6052 Page No.2450 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).
NC State Ports Authority [e-mail]
Company Name E-mail Address
2202 Burnett Blvd. 2202 Burnett Blvd.
Current Mailing Address Current Street Address
Wilmington, NC 28402 Wilmington, NC 28401
City State Zip City State Zip
Phone: Office#91 0-746-6460 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 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:
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)

(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). I agree to provide
corrected information should there be any change in the information provided herein.
Brian E. Clark Executive Director
Type,CIrrtne Title or Authority
S7 _ 111112,02i
ignature Date
I, 43iV.k. ,VirgoUUC , a Notary Public of the County of eAA) 1/t�r
State of North Carolina, hereby certify that Y ictu- E C lave,. 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 l7- day of „u.,tilt , 20 a4
GARRpT'.,, GalAWAAg
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_' ?My Comm. Exp. cp,= I My commission expires LIP . -0�7
m 12-12-2027. 6?
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NORTH NC Ports Authority Phone: [phone] Check: 202726
CAR O L I N A PO Box 9002 Fax: [phone]
P 0 R T f.� Wilmington, NC 28402-9002
1-f
Payment No.: 2004161520
NC DEPT OF ENVIRONMENTAL QUALITY Check Date: 01/18/2024
ENERGY MINERAL & LAND RESOURCES Vendor No.: 12362
1612 MAIL SERVICE CTR
RALEIGH NC 27699-1612
Page: 1 of 1
Invoice Our Tracking # PO/Contract # Gross Invoice
Invoice Number Date Remarks Amount* Discount Net Amount*
1 172024PERMITFE 01/17/2024 1907995727 1,400.00 0.00 1,400.00
AREA F WEST E&SC PERMIT FEE
Check Total $1,400.00
DETACH FROM CHECK AND KEEP FOR YOUR RECORDS
*Includes unplanned freight, if applicable
THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER.THIS DOCUMENT CONTAINS A GENUINE WATERMARK.THIS DOCUMENT HAS A VISIBLE AND INVISIBLE FLUORESCENT FIBERS.
NORTH 66-30
C A R O L I N A NC Ports Authority 531
PORT/ PO Box 9002 Check 202726
,1 Wilmington, NC 28402-9002
Date 01/18/2024
Void after One Year
PAY TO THE $ 1,400.00
ORDER OF
EB-$
NC DEPT OF ENVIRONMENTAL QUALITY DOIIAR3 94 994 44-4 44-1-)i-444 ONE COMMA FOUR ZERO ZERO HMO ZERO ZERO
ENERGY MINERAL & LAND RESOURCES
161E MAILSE2VICE CTR
RALEIGH NC 27699-1612
2
((/`----
First Citizens Bank and Trust Company Chairman of the Board
Wilmington, NC 28401-7515 Executive Director
THIS FORM CONTAINS MICROPRINT1NG