NCC242760_FRO Submitted_20240909

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 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 Area E Water Main Replacement - Canopy
2. Location of land-disturbing activity: County CUrtlberland City or Township Fort Liberty
Chicken Rd,Canopy Ln,Yadkin Rd 35,118 -79.012
Highway/Street Latitude(decimei degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence:September 5, 2024 1
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Military/Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.51
6. Amount of fee enclosed: $900 . 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 El Enclosed II No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jeremy George [e-mail]
_ —
Phone: Office# Mobile# 910=489-8862
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Department of Defense
Name Phone: Office# Mobile#
Cur_ent-M ihungAddr-ess ----- 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)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).
Old North Utility Services, Inc. [e-mail]
Company Name E-mail Address
P.O. Box 73316 2941 Logistics Street, Building N-6307
Current Mailing Address Current Street Address
Fort Liberty, NC 28307 Fort Liberty, NC 28310
City State Zip City State Zip
Phone: Office# 910-495-1311 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:
National Registered Agents, Inc. [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
-Raleigh, NC 27615 Raleigh, NC 27615 -_-
City State Zip City State Zip
Phone: Office# 919-844-8360 Mobile#
Jean Malcomson, Assistant Secretary
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 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.
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.
Timothy Loughman Utility Manager
Type or print name Title or Authority
Sig nure Date 1/ZY 4 t
I, Attrt, vkinardtg , a Notary Public of the County of (Ais>r O
State of North Carolina, hereby certify that"Thn *t \-0 �> n0A appeared personally
before me this day and being duly sworn acknowledged thbt the above form was executed by him/her.
Witness my hand and notarial seal,this 15114 day of z.t V) , 20, i11 „n,d,,,,„„,
Notary i
Seal - ' r
My commission expires A��� a.. L •"-,"

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.
Landowner 2 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 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#
Cur-rerttMailing-Addrosc CarreRt-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 9 in Part B 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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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#