NCC242597_FRO Submitted_20240827

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name P-658F Fitness Center and Combat Pool
Craven MCAS Cherry Point
2. Location of land-disturbing activity: County City or Township
Roosevelt Blvd 34.90556 -76.904444
Highway/Street Latitude(decimal degre Long itude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 9/30/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): _Federal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 17.3ac
6. Amount of fee enclosed 1800.00 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example: 8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes X Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Dale McFarland, E-mail Address CHPT_FAC_EADOMB©usmc.mil
- Environmental Affairs Officer
9. Phone: Office# 252-466-4599 Mobile# [phone]
10. Landowner(s) of Record (attach accompanied page to list additional owners):
MCAS Cherry Point, Commanding Officer _252-466-3807
Anthony Ference by Direction of the CO Phone: Office# Mobile#
Facilities Directorate Current Street Address:
PO BOX 8006 Facilities Directorate
MCAS Cherry Point, NC 28533-0006 87 Roosevelt Blvd
MCAS Cherry Point, NC 28533-0006
11. Deed Book No._Civil Docket No.63_Page No. 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).
MCAS Cherry Point- Commanding Officer [e-mail]
Anthony Ference by Direction of CO
Company Name E-mail Address
Current Mailing Address Current Street Address
Facilities Directorate Facilities Directorate
PO BOX 8006 B1, C St
MCAS Cherry Point, NC 28533-0006 _MCAS Cherry Point, NC 28533-0006
City State Zip City State Zip
Phone: Office# 252-466-3148/3807 Mobile#
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:
N/A
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:
N/A
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.
N/A
Company DBA Name
(d) If 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:
ADC Engineering, Inc. [e-mail]
Engineering firm or other consultant E-mail Address
Christopher B. Cook, P.E. 843-735-5141 843-991-7040
Individual contact person (type or print) Phone: Office# Mobile#
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.
Anthony A. Ference Deputy Facilities Director
Type or print name Title or Authority
Signature on file dated 23 March 2022, Washington Regional Office
Signature Date
, 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