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HomeMy WebLinkAboutNCC221619_FRO Submitted_20220427FINANCIAL 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 i@gmall.com Telephone252-426-4360 cell # 410-971-2462 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Harvey Point Defense Testing Activity (252)426-4360 (252)426-4369 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 (252 )426-4360 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: 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') S. `HNfwrnrrrrr � A a ' AAgry Seal; �CTARY My commission expires 11l3 t��• 'OUB LIG 'rnn uu+ 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 p@gmail.com Telephone252-426-4360 Cell # 410-971-2462 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Harvey Point Defense Testing Activity (252)426-4360 (252)426-4369 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 Oltjenl@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 (252)426-4360 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 p ` O'i AqKary Si -al,, My commission expires AU$ LPL �? '�Gi ` -