NCC230476_FRO Submitted_20230329

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING 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 and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. Project Name Pope Airfield 24 Inch Water Main Replacement Project-ON-00009-20
2. Location of land -disturbing activity: County Cumberland City or Township Fort Bragg
Highway/Street Manchester/Reilly Rd. Latitude 35.1808 Longitude 79.0019
3. Approximate date land -disturbing activity will commence: April 1, 2021 +/-
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Military/Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.67 ac.
$1,260(4ac. @
6. Amount of fee enclosed: $ $250 + 4 ac. Cad $65) The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
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 Jeremy George- Old North Utility Services E-mail Address [e-mail]
Telephone Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Department of Defense
Name Telephone Fax Number
Current Mailing Address Current Street Address
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.
Old North Utility Services, Inc.
Name
2941 Logistics Street, Building N-6307
Current Mailing Address
Fort Bragg NC 28310
City State Zip
[e-mail]
E-mail Address
2941 Logistics Street, Building N-6307
Current Street Address
Fort Bragg NC 28310
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
Fax Number
(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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
Fax Number
(c) In 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:
Shipman Engineering, PLLC
Engineering Firm or other consultant
Zak Shipman, PE
Individual contact person (type or print)
[e-mail]
E-mail Address
. �U'
Telephone
Fax Number
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.
Adam Loughman
Type or print name
Sig
Utility Manager
Title or Authority
C[j �t7(C�Z
Date
I, Elf n a-T �S , a Notary Public of the County of C, Lk V'�� 6 m 1.
State of North Carolina, hereby certify that 1))o \AkA IQU 6MVYy.PJV(0� appeared personally
before me this day and being duly sworn acknowledged thal the abovbform was executed by him.
Witness my hand and notarial seal, this day of ^20
Nof:dry _
gaoa t/tt se1*3 uolssltuwoc W My commission expires
euryweC 4upN
1lunoo puBNegwn
olignd tie;oN
sowed euel3