NCC223347_FRO Submitted_20220927

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
Project Name: Slocum Road Entry Control Facilities ECF - P134
Location of land -disturbing activity: County Craven City or Township Havelock/Cherry Point
Highway/Street: Slocum Road Latitude(decimal degrees): 34.918573 Longitude(decimai degrees):-76.929375
3. Approximate date land -disturbing activity will commence: June 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Federal Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 76 Acres
6. Amount of fee enclosed: $7,600. The application fee of $100.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: 8.10-acre application fee is $900). Checks should be
addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Dale McFarland (Environmental Affairs Officer) E-mail Address: [e-mail]
Phone: Office # . 25( 2 f 466-4599 Mobile # 25Z 675-8442
9. Landowner(s) of Record (attach accompanied page to list additional owners):
COMMANDING OFFICER —Marine Corr:s Air Station Chery Point 252 466-3148 (252_) 466-2832 NA
Name Phone: Office Fax Mobile
Facilities Directorate
MARINE CORPS AIR STATION
P.O. Box 8006
Cherry Point NC 28533-0006
Current Mailing Address
Facilities Directorate
MARINE CORPS AIR STATION
Building 1 C Street
Cherry Point NC 28533-0006
Current Street Address
10. Deed Book No. United States of America (civil action): Civil Docket No. 63

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Commanding Officer
Anthony A Ference by Direction Anthon .ference usmc.mil [phone]/3807 {252] 466-2832 NA
Name E-mail Address Phone: Office Fax Mobile
FACILITIES DIRECTORATE
ATTN: Anthony A. Ference
P.O. Box 8006
Cherry Point NC 28533-0006
FACILITIES DIRECTORATE
MARINE CORPS AIR STATION
Building 1 C S
Cherry Point NC 28533-0006
current mamng Haaress t.,urrent otreet muuress
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
NA
Name of Registered Agent
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
NA
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Anthony A Ference by Direction
Type or print name
NA: On File March 23, 2022
Signature
Deputy Facilities Director
Title or Authority
Date
I, NA: On File March 23, 2022, a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this day of
Notary
My commission expires
,20

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
NA
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
Deed Book No.
Landowner 3 of Record:
NA
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
NA
Name
Current Mailing Address
City
Deed Book No.
Landowner 5 of Record:
NA
Name
Current Mailing Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
State
Phone: Office # Mobile #
Current Street Address
Zip City State Zip
Page No. _ Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City
Page No.
City State
Deed Book No.
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
Zip City State Zip
Page No._ Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
NA
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State
Zip City State
Phone: Office #
Mobile #
NA
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Phone: Office #
Mobile #
NA
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Phone: Office #
Mobile #
NA
Comnanv 5 NamP
Aririrno.
(:i1rrP.nt Strppt Aririress
Zip
Zip
Zip
City State Zip City State Zip
Phone: Office # Mobile #