NCC215603_FRO Submitted_20211008

FINANCIAL 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: P254 Station Academic Facility/Auditorium
Location of land -disturbing activity: County: Craven City or Township: Cherry Point/Havelock
Highway/Street: Roosevelt Blvd. Latitude: 34.901949 N Longitude:-76.905718 W
Approximate date land -disturbing activity will commence: August 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Military
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11 acres
6. Amount of fee enclosed: 2,715. 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 George Radford
Telephone [phone]
E-mail Address George.radforda-usmc.mll
Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Maine Corps Air Station Cherry Point Telephone: [phone] & [phone] FAX: NA
Mailing Address
FACILITIES DIRECTORATE
MARINE CORPS AIR STATION
P.O. Box 8006
Cherry Point NC 28533-006
Street Address
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
Anthonv A. Ference by Direction email: Anth
Telephone: [phone] & [phone]
ference(d)usmc.mil
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 Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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:
NA
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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:
CATLIN Engineer & Scientist
Engineering Firm or other consultant
M. Robin Austin, P.E.
Individual contact person (type or print)
robin.austina-catlinusa.com
E-mail Address
[phone] NA
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
Type or print name
NA: Blanket Coverage dated August 17, 2020
Signature
Date
Deputy Facilities Director
Title or Authority
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