NCC221619_FRO Submitted_20220427

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. HarveyPoint RRepair
1. Project Name Runway
2. Location of land -disturbing activity: County Perquirnans City or Township Hertford
Highway/Street Harvey Point Road Latitude 36 05' 53" N Longitude 76 19' 34" W
3. Approximate date land -disturbing activity will commence: April 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): U.S. Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.04 Acres
6. Amount of fee enclosed: $ 650.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name HPDTA E-mail Address Oltjen 1 [e-mail]
Telephone[phone] cell # 410-971-2462 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harvey Point Defense Testing Activity [phone] [phone]
Name Telephone Fax Number
2835 Harvey Point Road
Current Mailing Address Current Street Address
Hertford, NC 27944
City State Zip City State Zip
10. Deed Book No. NA Page No, NA 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 maybe listed as the financially responsible party.
Harvey Point Defense Testing Activity Oltjen1 @gmail.com
Name E-mail Address
2835 Harvey Point Road 2835 Harvey Point Rd.
Current Mailing Address Current Street Address
Hertford, NC 27944 Hertford NC 27944
City State Zip City State Zip
Telephone [phone] 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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(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:
N/A
NIA
Name of Registered Agent
E-mail Address
NIA
N/A
Current Mailing Address
Current Street Address
N/A
N/A
City State Zip
City State Zip
Telephone N/A Fax Number N/A
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.
Michael T. Clark
Type or print name
, L ('
Signature
Director, HPDTA
Title or Authority
Date
Gerri White , a Notary Public of the County of Perquimans
State of North Carolina, hereby certify that Michael T. Clark appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
st
Witness my hand and notarial seal, this .�>r day of C- r7 L,-j 20 _V')
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My commission expires 11l3
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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. 1. Project Name Harvey Point Runway Repair
2. Location of land -disturbing activity: County PerC uimanS City or Township Hertford
Highway/Street Harvey Point Road Latitude 36 05' 53" N
Longitude 76 19' 34" W
I Approximate date land -disturbing activity will commence: April 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): U.S. Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.04 Acres
6. Amount of fee enclosed: $ 650.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameHPDTA
E-mail Address Oltjenl [e-mail]
Telephone[phone] Cell # 410-971-2462 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Harvey Point Defense Testing Activity
[phone] [phone]
Name
Telephone Fax Number
2835 Harvey Point Road
Current Mailing Address
Current Street Address
Hertford, NC 27944
City State Zip
City State Zip
10. Deed Book No. NA Page No NA 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.
Harvey Point Defense Testing Activity
[e-mail]
Name
E-mail Address
2835 Harvey Point Road
2835 Harvey Point Rd.
Current Mailing Address
Current Street Address
Hertford, NC 27944
Hertford NC 27944
City State Zip
City State Zip
Telephone [phone]
Fax Number (252 )426-4352

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:
N/A N/A
Name
N/A
Current Mailing Address
N/A
City State Zip
Telephone N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip
Fax Number N/A
(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:
N/A N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
E-mail Address
N/A
Current Street Address
N/A
City State Zip City State Zip
Telephone N/A Fax Number NIA
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.
Michael T. Clark
Type or print name
r
Signature
Gerri White
Director, HPDTA
Title or Authority
Date
a Notary Public of the County of Perquimans
State of North Carolina, hereby certify that Michael T. Clark appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this .11 day of • J&^ r) z LZ,r- 20
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O'i
AqKary
Si -al,,
My commission expires
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