NCC220328_FRO Submitted_20220118

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 CLB 2ND 6TH 8TH HEADQUARTERS (131199)
2. Location of land -disturbing activity: County Onslow City or Township Camp Lejeune
Highway/Street Conner Street Latitude 34�38' 49" N Longitude "
3. Approximate date land -disturbing activity will commence: February 1, 2022__
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Federal Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.81
6. Amount of fee enclosed: $ 2 800 The Express Permitting application fee is a dual charge.
The normal fee of sloo.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 Talia Prendergast _ E-mail Address taila.barracoO usmc.mil_.
Telephone (910)_451-3238 x 3242 Cell #
Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Commanding General, MCB Camp Lejeune [phone]
Name Telephone
1005 Michael Road
Current Mailing Address
Camp Lejeune, NC 28547
City State Zip
Current Street Address
City
State
[phone]
Fax Number
Zip
10. Deed Book No. NIA Page No. NIA 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.) tf 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
Name
1005 Michael Road
Current Mailing Address
Camp Lejeune, NC 28547
City State Zip
Telephone [phone]
E-mail Address
Current Street Address
City State Zip
Fax Number [phone]

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:
Name of Registered Agent
Current Mailing Address
E mail Address
Current Street Address
City State Zip City State Zip
Telephone 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:
Michael Baker International [e-mail]
Engineering Firm or other consultant E-mail Address
Lauren Greenfield, P.E. [phone] 412-375-3980
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,
Talia Prendergast PWD Civil Engineer
Type or print name Title or Authority
Si ature Date
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I,rf jM'T) • _ , a Notary Public of the County of ILh4htz 11�
State of North Carolina, hereby certify that L911 appeared personally
before me this day and being duly sworn acknowledged that the above"form was executed by him.
Witness my hand a,o' fi�i'i�isy, day of Sn:A4 20�
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