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HomeMy WebLinkAboutNCC221075_FRO Submitted_20220408FINANCIAL 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 and/or fax information unavailable, place N/A in the blank.) Part A. 1. Project Name: Building 1016 Renovation 2. Location of land -disturbing activity: County: Craven City or Township: Cherry Point/Havelock Highway/Street: 6th Ave Latitude: 34.907560 N Longitude:-76.895735 W 3. Approximate date land -disturbing activity will commence: October 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Military 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.9 acres 6. Amount of fee enclosed: 5 630.00 The Express Permitting application fee is a dual charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). 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 Dale McFarland _ E-mail Address Dale. mcfarlandOusmc.mil Telephone (252) 466-4598 Cell # i 252 � 675-8442 Fax # (252) 466-2000 9. Landowner(s) of Record (attach accompanied page to list additional owners): Maine Corps Air Station Cherry Point Telephone: (252) 466-3148 & (252) 466-3807 FAX: NA Mailing Address FACILITIES DIRECTORATE MARINE CORPS AIR STATION P.O. Box 8006 Cherry Point NC 28533-006 Strppt Adrlrp.RS FACILITIES DIRECTORATE MARINE CORPS AIR STATION Building 1 C Street Cherry Point NC 28533-006 10. Deed Book No. Military Reservation Page No. Numerous 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. Marine Corps Air Station Cherry Point Commanding Officer Anthony A. Ference by Direction _ _ email: Anthony.ference(a)usmc.mil Telephone: (252) 466-3148 & (252) 466-3807 Fax Number: NA 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: NA Name Current Mailing Address City State Telephone E-mail Address Current Street Address Zip City Fax Number State Zip (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: Name of Registered Agent Current Mailing Address City Telephone _ E-mail Address Current Street Address State Zip City State Zip Fax Number (c) In 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: Calibre Engineering hresnik calibre -en ineerin .com Engineering Firm or other consultant E-mail Address Howard Resnik, PE (910) 791-4441 NA Individual contact person (type or print) Telephone 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. Anthony A. Ference Deputy Facilities Director Type or print name Title or Authority NA: Blanket Coverage dated August 17. 2020 Signature Date I, NA: Blanket Coverage dated August 17. 2020 a Notary Public of the County of 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. Witness my hand and notarial seal, this day of Seal ,20 Notary My commission expires