NCC230468_FRO Submitted_20230216

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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: P197 Hangar & Parking Garage Construction
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
Location of land -disturbing activity: County: Craven City or Township: Havelock/MCAS Cherry Point
Highway/Street: Airfield & 6t" Ave Latitude (decimal degrees): 34.904 Longitude (decimal degrees):-76.891
3. Approximate date land -disturbing activity will commence: 02/01/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Federal Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 28.87 acres
6. Amount of fee enclosed: $2,900 (2 acres paid previously $200- remaining fee due $2,700). 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Dale McFarland E-mail Address: dale. mcfarlandausmc.mil
Phone: Office # 252-466-4599 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
COMMANDING OFFICER- Marine Corps Air Station Cherry Point
Anthony A. Ference by direction 252-466-3148 252-466-2832
Name Phone # Fax #
Facilities Directorate
Attn: Anthony A. Ference
P.O. Box 8006
Cherry Point NC 28533
Current Mailing Address
Building 1, C Street
Cherry Point NC 28533
Current Street Address
10. Deed: 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- Marine Corps Air Station Cherry Point
Anthony A. Ference by direction [e-mail]
Company Name
Facilities Directorate
Attn: Anthony A. Ference
P.O. Box 8006
Cherry Point NC 28533
E-mail Address
Building 1, C Street
Cherry Point NC 28533
Current Mailing Address Current Street Address
Phone: Office # 252-466-3631 Mobile # NA FAX # [phone]
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 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:
NA
Name of Registered Agent 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.
NA
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.
NA : On File March 23, 2022
Type or print name Title or Authority
Signature
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 , 20
Notary
Seal
My commission expires

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.
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
State
Zip
City State Zip
Deed Book No.
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.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City State
Zip
Phone: Office #
Mobile #