NCC242685_FRO Submitted_20240919

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 1 -1
S
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 NCGO1 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 N/A in the blank.)
Part A.
1. Project Name Dosher Memorial Hospital Main Campus ED Addition
*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 Brunswick City or Township Southport
Highway/Street 924 N Howe St 33.929 lt -78.021Latitude(decmad degrees)) Longude(decimai degrees)
3. Approximate date land-disturbing activity will commence: 8/1/24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial (Hospital)
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .03
6. Amount of fee enclosed: $200.00 . 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 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name John S. Tunstall, P.E. E-mail [e-mail]
Phone: Office# 910-343-9653 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dosher Memorial Hospital 910-457-3800 910-619-8554
Name Phone: Office# Mobile #
924 N. Howe Street 924 N. Howe Street
Current Mailing Address Current Street Address
Southport NC 28461 Southport NC 28461
City State Zip City State Zip
Page No. 0671
10. Deed Book No, 3511 Provide a copy of the most current deed.

PartB. 1V - C3111)
(gbi . 011 •►5.ai-n
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).
Dosher Memorial Hospital [e-mail]
Company Name E-mail Address
924 N. Howe Street 924 N. Howe Street
Current Mailing Address Current Street Address
Southport NC 28461 Southport NC 28461
City State Zip City State Zip
Phone: Office# 910-457-3800 Mobile# [phone]
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:
Lynda Stanley, CEO [e-mail]
Name of Registered Agent E-mail Address
924 N. Howe Street 924 N. Howe Street
Current Mailing Address Current Street Address
Southport NC 28461 Southport NC 28461
City State Zip City State Zip
Phone: office# 910-457-3800 Mobile# [phone]
N/A
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 companynotregiabaoedanddoingbusineoaunderananaumedname. aftochacnpy
of the Certificate mf Assumed Name.
Company DBAName
The above information is true and correct to the best of my knowledge and belief and was provided
bvnne under oath. (This form must be signed by the Financially Responsible Person ifanindividua|(a)
or his aftonley-in-fact, or if not an iOdjvjdua), by an offioer, director, partner. or registered agent with
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the authority to execute instruments for the Financially Responsible Party). | agree to provide
corrected inforOoatioOshould there be any change in the info[OD@tionprovided
-'herein.
Lynda Stanley CEO
Tvprint Title UrAuthority
Signa+U'e / � Da
|. C' , a Notary Public ofthe County of ^ C'K
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State of North Carolina, hereby certify that ���� ��u�_ appeared personallybefnnsnnethiadaymndbeinQdulyavvornecknovv|"°+Aadthattheobovofor~~�-oexeoutedbvhim/her.
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VWtneoamy hand and notarial seal, this � » dayof -.>���m 4C- . 20 2LJ
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