NCC215568_FRO Submitted_20211007

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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. Sentara Albemarle Medical Center - Phase 1 Medical Office Building
1. Project Name
2. Location of land -disturbing activity: County Pasquotank City or Township Elizabeth City
Highway/Street Halstead Blvd/Thunder Road Latitude 36017'55.44"N Longitude 76016'9.49"W
3. Approximate date land -disturbing activity will commence: September 27, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional/Commercial (Medical)
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 21.59
6. Amount of fee enclosed: $ $5,430.00 The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per 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). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Carl Gaborik Email Address CWGaboriesentara.com
Telephone [phone] cell # 757.814.7052 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MPB Inc.
757.594.1011 757.594.1001
Name
Telephone Fax Number
6015 Poplar Hall Dr
6015 Poplar Hall Dr
Current Mailing Address
Current Street Address
Norfolk VA 23502
Norfolk VA 23502
City State Zip
City State Zip
1295 188
10. Deed Book No. Page No.
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.
MPB, Inc. d/b/a MPB, Inc. Carolina
Name
E-mail Address
160 Mine Lake Ct., Suite 200
160 Mine Lake Ct., Suite 200
Current Mailing Address
Current Street Address
Raleigh NC 27615-6417
Raleigh NC 27615-6417
City State Zip
City State Zip
Telephone
Fax Number

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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
CT Corporation System
Name of Registered Agent E-mail Address
160 Mine Lake Ct., Suite 200 160 Mine Lake Ct., Suite 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Telephone
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:
VHB Engineering NC, P.C. [e-mail]
Engineering Firm or other consultant E-mail Address
John D. Hines, PE 757.490.0132 757.490.0136
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.
Aubrey L. y 2jz2 President
Type or pri �na Title or Authority
09/16/2021
Signature Date
Anita C. Fritzinger , a Notary Public of the4"Fft of Norfolk
V1Rrq)N/4- Aubrey y L. Layne
State of 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 16th day of September 20 21
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F Notary
Seal ' 1?0� •:
s My commission expires 11/30/2022
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