NCC215950_FRO Submitted_20211027

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 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 Environment and Natural Resources. (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: CFCC — Electric Lineworkers Overhead and Underground Training Facility
2. Location of land -disturbing activity: County: New Hanover City or Township: Castle Hayne
Highway/Street: —3200 Education Loop Road Latitude: 34.3205 N Longitude: 77.8765 W
3. Approximate date land -disturbing activity will commence: As soon as permitted
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.4 acres
6. Amount of fee enclosed: $195.00. The application fee of $65.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes: No: X Enclosed:
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Jim Morton E-mail Address: Imortonacfcc.edu
Telephone: (910) 362 — 7065 Cell #:
Fax #: (910) 362 — 7046
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cape Fear Community College _
Name
411 North Front Street
Current Mailing Address
Wilmington. NC 28401
City State Zip
10. Deed Book No: 2458 Page No: 0273 & 0277
Part B.
(910) 362 — 7065 910 362 —7046
Telephone Fax Number
411 North Front Street
Current Street Address
Wilmington, NC 28401
City State Zip
Provide a copy of the most current deed.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Cape Fear Community College
Name
411 North Front Street
Current Mailing Address
_Wilmington. NC 28401
City State Zip
Telephone: (910) 362 — 7065
0morton(&cfcc.edu
E-mail Address
411 North Front Street
Current Street Address
Wilmington, NC 28401
City State Zip
Fax Number: (910) 362 — 7046

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
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
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.
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Type or print name Title or Authority
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Signa a Date
I, (. `1 I ` '1� a Notary Public of the County of Pf ri C(fl-
State of North Carolina, hereby certify that 0" %�Or-oyy appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness m notarial seal, this day of 1�(c�. c �� 20�_
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NOTARy a Notary
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