NCC241801_FRO (County Corrected)_20240613

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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 NIA in the blank.)
Part A.
1. Project Name Beaufort Maritime Education Center
"If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County Craven City or Township Beaufort
HighwaylStreet293 Est Beaufort Rd. Ext.Latitude(decimal degrees)34.7280 Longltude(decimal degrees) -76.6660
3. Approximate date land-disturbing activity will commence: Upon Receipt of Permit
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13 Acres
6. Amount of fee enclosed: $ 1,300 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Erin Lawrence E-mail Address erin.lawrence(,cc dncr.nc.gov
Phone: Office# 919-814-6613 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
State of North Carolina through DNCR 919-814-6613
Name Phone. Office# Mobile#
4605 Mail Service Center
Current Mailing Address Current Street Address
Raleigh, NC 27699-4605
City State Zip City State Zip
10. Deed Book No. 802 Page No. 480 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).
Company Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Note: If the Financially Responsible Parry 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:
NC Department of Natural&Cultural Resources [e-mail]
Name of Registered Agent E-mail Address
4605 Mail Service Center
Current Mailing Address Current Street Address
Raleigh, NC 276994605
City State Zip City State Zip
Phone: Office# 919-814-6613 Mobile#
Erin Lawrence
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:
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 rider
which the company is Doing Business As. If the Financially Responsible Party is an individual, G neral
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
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 individulal(s)
or his attomey-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.
Staci Meyer Chief Deputy Secretary
Type o not name Title or Authority
41 YZzvz4
Sicyature A- Date
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�;M�11 es , a Notary Public of the County of tAla ke
State of North Carolina,hereby certify that '5�raG Mf e! appeared personally
before me this day and being duly sworn acknowledged that th above form was executed by him/her.
Witness my hand and notarial seal, this W- day of Pcpri 20
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