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HomeMy WebLinkAboutNCC220328_FRO Submitted_20220118FINANCIAL 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 (910) 451-2212 Name Telephone 1005 Michael Road Current Mailing Address Camp Lejeune, NC 28547 City State Zip Current Street Address City State (910) 451-2927 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 (910) 451-2212 E-mail Address Current Street Address City State Zip Fax Number (910) 451-2927 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 lauren.greenfield@mbakerintl.com Engineering Firm or other consultant E-mail Address Lauren Greenfield, P.E. (412) 269 2939 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 -----A,/ — 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� �r •.(dslon C3 0SARY �" otary SDI t� �•" Os AUgOC' rJ $ My commission expires e�DZA