NCC220153_FRO Submitted_20220110

RECEIVED
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM i'JUV 0 4 2021
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by thtt'dt`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 CCHC - Main Campus
2. Location of land -disturbing activity: County Craven City or Township New Bern
Highway/Street 1010 Medical Park Ave -Latitude 35.106236 Longitude -77.092757
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.0
00
6. Amount of fee enclosed: $ 130.. 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bobby Evans E-mail Address [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
CCHC Properties, LLC 252-514-6685
Name Telephone Fax Number
P.O. Box 12248 1020 Medical Park Avenue
Current Mailing Address Current Street Address
New Bern NC 28561 New Bern NC 2856
City State Zip City State Zip
10. Deed Book No. 2344 page No. 591 Provide a copy of the most current deed.
Part B.
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): n
CCHC Properties, LLC it V C K p US & CC n e0\L -[n C ai 2. CO V'n
Name E-mail Address
P.O. Box 12248 1020 Medical Park Avenue
Current Mailing Address
New Bern NC 28561
City
Current Street Address
New Bern NC 28561
State Zip City
State
Telephone [phone] Fax Number
Zip

RECEIVED
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: NO U 42021
Name
Current Mailing Address
City
Telephone
E-mail Address
IT^`-11tants, PA
Current Street Address
State 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
Pa�rtty isk
a Corporation, give name and street address of the Registered Agent: }
�y/.'C 'tI 3eO 11 �'J"V1 IMS J (� cl k vJ ),e I . Cc "4'
Name of RegJ�istered Agent E-mail Address /�
/o Zc? Ao'�.-e-a l � l A �✓ t /0 � /r//or/(�-e, 1P111 14,,l &lL
Current Mailing Address Current Street Address
ile
City State Zip City State Zip
Telephone Z Sz , Sig/ Fax Number Z SZ . SN. Z 145—
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.
S fe L-j W . �%u C �o I I /vre_ Ll'llt? 4 a,?s [r
Type o print name Title or Authority
I i / 2�2
Signature Date
vy Wk"e/ , a Notary Public of the County of
State of North Carolina, hereby certify that S %ip W �u ,k,� S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
s� Nov► -
Witness my hand and ngii����l seal, this � day of 20 21
`\`�8 011Y W ��C
v� CIO&
Notary Public
Craven Notary
Seal County
11 My commission expires 2 Q, Z�Z
/
CAR1�\�������