NCC220319_FRO Submitted_20220118

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 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.
8TH REGIMENTAL HQ BLDG REPLACEMENT (P1520)
Project Name
Location of land -disturbing activity: County ONSLOW City or Township
Highway/Street "A" STREET Latitude34.667389385382556 tbngitude
3. Approximate date land -disturbing activity will commence
JAN 15, 2022
CAMP LEJEUNE
77.350172511301429 W
4. Purpose of development (residential, commercial, industrial, institutional, etc.): FEDERAL OFFICE BLDG
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.55 ACRES
300.00 too
6. Amount of fee enclosed: $ The application fee of $4.9 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 Enclosed YES
8. Person to contact should erosion and sediment control issues arise durin land -disturbing activity:
cmoog yn:lconstruction.com
Name Cordon Moog, Jared Grimes E-mail Address [e-mail]
Telephone [phone] Cell #
SAME Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Commanding General, MCB Camp Lejeune
Name
MCBCL Public Works Division, Civil Branch
Current Mailing Address
CAMP LEJEUNE, NC 28547
City State
[phone]
Telephone
Fax Number
1005 MICHAEL ROAD [e-mail]
Current Street Address
CAMP LEJEUNE, NC 28547
Zip City
State
Zip
10. Deed Book No. NA Page No. NA Provide a copy of the most current deed.
Part B.
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.
Commanding General, MCB Camp Lejeune [e-mail]
Name E-mail Address
MCBCL Public Works Division, Civil Branch 1005 MICHAEL ROAD
Current Mailing Address
CAMP LEJEUNE, NC 28547
City State Zip
Current Street Address
CAMP LEJEUNE, NC 28547
City
State
Zip

Telephone 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 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, g've 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
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.
Talia Prendergast
Type or print name
Civil Design Branch, MCBCL Public Works Division
Title or Authority
11 1,4 ZI
Signature Date
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I, a Notary Public of the County of
State of North Carolina, hereby certify that -A`1Ct � appeared
personally before me this day and being duly sworn acknowledged fhat the above form was executed
by him.
Witness my
al seal, this �� day of V WVA , 241A1
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Notary
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