NCC215388_FRO Submitted_20210930

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 befo•e 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 a -mail and?
or fax information unavailable place N`A in the blank.)
Part A. Marine Corps Engineering School, MCES P1312
1 Project Name p 9 9
2. Location of land -disturbing activity: CountyOnsioW City or TownshipCamp Lejeune
Highway/Street Horn Rd Latitude 34.582540 Longitude-77.363075
3 Approximate date land -disturbing activity will commence: October 20, 2021
4 Purpose of development (residential, commercial, industrial. institutional etc ) Military
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas)- 7.3
6 Amount of fee enclosed- S520 . The application fee of $65 00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example a 9-acre applicat=on fee is $585).
7 Has an erosion and sediment control plan been filed? Yes No Enclosed X
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity
Name Talia Prendergast E-mail [e-mail]
Telephone [phone] x3242 Cell # Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners)
Marine Corps Base Camp Lejeune [phone] [phone]
Name Telephone Fax Number
1005 Michael Rd
Current Mailing Address Current Street Address
Camp Lejeune, NC 28547
City State Zip City State Zip
10. Deed Book No N/A Page No. N/A 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 ) if the company or firm is a sole proprietorship
the name of the owner or manager may be listed as the financially responsible party.
Commanding General MCB Camp Lejeune
Name
1005 Michael Rd.
E-mail Address
Current Mailing Address Current Street Address
Camp Lejeune, NC 28547
City State Zip City State Zip
Telephone[phone] Fax Number(910) 451-3300

2 (a) If the Financially Responsib"•e Party is not a resident of North Carolina give name and street address
of the designated North Carolina Agent
HAI
Name
Current Mailing Address
City State
Telephone,
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in bus.-ness 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
NA
Name of Registered Agent E-mail Address
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This fora must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact. or if not an individual, by an officer. d rector. 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.
Talia Prendergast
Type or print name
MCBCL Public Works Division
Title or Authority
_2. Au.a Uzi
Signature V Date
I. a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and be-ing duly sworn acknowledgea that the above form was
executed by him
Witness my hand and notarial seal th s aL day of 20 Q1
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♦ '`s Notary
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