NCC233566_FRO Submitted_20231204

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: NCNG Reidsville Renovation and Addition
2. Location of land-disturbing activity: County Rockingham City or Township: Wentworth
Highway/Street: NC-65 Latitude 36.388701 N Longitude -79.749496 W
3. Approximate date land-disturbing activity will commence August 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional/Military
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.61 acres
6. Amount of fee enclosed: $ 1,890.00. 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 ✓
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name LTC Robyn Bryant E-mail Address robyn.s.bryant.mil([e-mail]
Telephone [phone] Cell # 828-320-8053 Fax# None
9. Landowner(s)of Record (attach accompanied page to list additional owners):
North Carolina National Guard 919-345-6137 None
Name Telephone Fax Number
1636 Gold Star Drive, Suite 2600 1636 Gold Star Drive, Suite 2600
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
10. Deed Book No. 772 &709 Page No. 2263 &321 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.)
North Carolina National Guard rodney.d.newton.mil(amail.mil
Name E-mail Address
1636 Gold Star Drive, Suite 2600 1636 Gold Star Drive, Suite 2600
Current Mailing Address Current Street Address
Raleigh NC 27607 Raleigh NC 27607
City State Zip City State Zip
Telephone [phone] Fax Number None

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:
N/A
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:
N/A
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:
Timmons Group frank.slinskyAtimmons.com
Engineering Firm or other consultant E-mail Address
Frank Slinsky Ill, PE 919-866-4505 919-859-5663
Individual contact person (type or print) 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.
Rodney D. Newton FMO—Facility Management Officers
Type or print name Title or Authority
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Signature Date
I, '(UY)CLrl-� ./`ACU ► , a Notary Public of the County of \A;60L
State of North Carolina, hereby certify that ' Cluk ,`-k ( -& lE_ Qt 1 appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand illf wtarial seal, this ��-) day of 1fl O « L.\ , 20 0l l
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