NCC230362_FRO Submitted_20230209

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. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
1. Project Name Ft Fisher - National Guard Replacement
2. Location of land -disturbing activity: County New Hanover City or Township Kure Beach
Highway/Street 116 Air Force Way Latitude33.980618 Longitude-77.916986
3. Approximate date land -disturbing activity will commence: January, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.61
6. Amount of fee enclosed: $325 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:
NameJoshua Cheatwood E-mail Address [e-mail]
Telephone [phone] cell # 318.347.3888 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
USA AIR FORCE
919.722.5143
Name
Telephone Fax Number
1095 Peterson Avenue
1095 Peterson Avenue
Current Mailing Address
Current Street Address
Goldsboro, NC 27531
Goldsboro, NC 27531
City State Zip
City State Zip
10. Deed Book No. Page No.
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.
United States Army National Guard
rodney.d.newton.mil(_aarmy.mil
Name
E-mail Address
1635 Gold Star Dr Suite: 2600
1635 Gold Star Dr Suite: 2600
Current Mailing Address
Current Street Address
Raleigh, NC 27607
Raleigh, NC 27607
City State Zip
City State Zip
Telephone [phone]
Fax Number

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
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
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.
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Signature
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Title or Authority
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Date
I, Vy c1cb b c,/ I , a Notary Public of the County of w" c,
State of North Carolina, hereby certify that _RD GL/1e c t -D • WCW t3V1 appeared
personally before me this day and being duly sworn 4knowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 25A day of Ki 20 212-
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