NCC215972_FRO Submitted_20211109

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Currituck Water & Sewer - Eagle Creek WWTP to Fost - Sanitary Force Main
2
city or Township Moyock
Highway/Street Survey Rd Latitude 36.490088 Longitude-76.168695
3. Approximate date land -disturbing activity will commence: September 2021
4
Location of land -disturbing activity: Count Currituck
Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.0
6. Amount of flee enclosed: $ 1,890 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Strum E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attachment
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
Currituck Water and Sewer, LLC [e-mail]
Name E-mail Address
4700 Homewood Ct. Suite 108 4700 Homewood Ct. Suite 108
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] 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:
Forrest Firm, P.C.
[e-mail]
Name of Registered Agent
E-mail Address
3700 Glenwood Ave. Suite 240
3700 Glenwood Ave. Suite 240
Current Mailing Address
Current Street Address
Raleigh NC 27612
Raleigh NC 27612
City State Zip
City State Zip
Telephone [phone]
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:
Bissell Professional Group
[e-mail]
Engineering Firm or other consultant
E-mail Address
David Klebitz
252-261-3266
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.
Kenneth Rab r
Ty:2r/
Sig a
Manager
Title or Authority
Date
a Notary_RILbLic of the County of
ry State of Nenth G-81101iea, hereby certify thatappeared personally
before me this day and being duly sworn acknowledged at the above form was executed by him.
Witness my hand angf nptarial seal, this day of
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