NCC221158_FRO Submitted_20220325

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 and/
or fax information unavailable, place NIA in the blank.)
Part A. MACS-2 Automotive Organizational Shop P685 1. Project Name g p ( )
2. Location of land -disturbing activity: County OnsloW City or Township Camp Lejeune
HighwaylStreet Perimeter Road Latitude34.702360 Longitude-77.439205
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc,) Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas)' 2 Acres
6. Amount of fee enclosed: $ 130 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application 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 Address talla. [e-mail]
Telephone [phone] x3242 Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners),
Commanding General, MCB Camp Lejeune [phone] [phone]
Name Telephone Fax Number
1005 Michael Road
Current Mailing Address Current Street Address
Camp Lejeune, NC 28547
City State Zip City State zip
10. Deed Book No. NA Page No. 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 E-mail Address
1005 Michael Road
Current Mailing Address Current Street Address
Camp Lejeune, NC 28547
City State zip City State Zip
Telephone [phone]x3242 Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
E-mail Address
Current Mailing Address
Current Street Address
City State Zip
City State Zip
Telephone
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
Engineer/ assumed name, attach a copy of the Certificate
of Assumed Name. If the Financially Responsible
Consultant Party is a Corporation, give name and street address of the Registered Agent:
Meredith Cutchin, PE NAVFAC
[e-mail]
Name of Registered Agent
E-mail Address
NAVFAC MIDLANT Z-144,1st Floor 9324 Virginia Avenue
Current Mailing Address
Current Street Address
Norfolk, VA 23511
City State Zip
City State Zip
Telephone [phone]
Fax Number NIA
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Talia Prendergast
Type or print name
Civil Engineer, Public Works Division
Title or Authority
a to MMR 202.1
Signature UDate
a Notary Public of the County of _
State of North Carolina, hereby certify that V'14 appeared
personally before me this day and being duly sworn acknowledged t t the above form was
executed by him.
Witness my hand and notarial seal, this 4�day of MCXACr\ ,;�a I _
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