NCC223517_FRO Submitted_20221013

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PRMITTING OPTION
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 Fayetteville State University Bryant & Vance Hall Demolition
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Murchison Rd. Latitude(decimal deg.) 35.0694 Longitude(decimal deg.)-78.8917
3. Approximate date land -disturbing activity will commence: November 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0
6. Amount of fee enclosed: $ 1,750 . The Express Permitting application fee is a dual charge. The
normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In
addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Harold Miller E-mail Address hmillero_uncfsu.edu
Phone: Office # 910-672-1952 Mobile #
301-257-9418
Landowner(s) of Record (attach accompanied page to list additional owners):
Fayetteville State
Name
1200 Murchison Road
Current Mailing Address
910-672-1403 910-309-8824
Phone: Office # Mobile #
Same
Current Street Address
Fayetteville NC 28301 Same
City State Zip City State Zip
10. Deed Book No. 2412 Page No. 593 Provide a copy of the most current deed.

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).
Fayetteville State [e-mail]
Company Name E-mail Address
1200 Murchison Road
Current Mailing Address
Fayetteville NC 28301
City State Zip
Same
Current Street Address
Same
City State Zip
Phone: Office # 910-672-1403 Mobile #
910-309-8824
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:
n/a
Company Name
E-mail Address
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:
n/a
Company Name E-mail Address
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)

(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
(d) If 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:
CLH Design, PA
Engineering firm or other consultant
Steve Miller
Individual contact person (type or print)
[e-mail]
E-mail Address
919-319-6716x4012 919-443-4067
Phone: Office # Mobile #
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.
Greg Lovins
or print name T7 M '-) P k2L�
Sign r
Interim Vice Chancellor, Business & Finance
Title or Authority
Flo- 1 2-0 2-2
I, 75—re" ce ge �r� , a Notary Public of the County of
State of North Carolina, hereby certify that Cr L0S appeared personally
before me this day and being duly sworn acknowled@6d that the above form was executed by him/her.
Witness my hand and notarial seal, this =day of 20 ZZ
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My commission expires
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