NCC221333_FRO Submitted_20220426

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 and/or fax
information unavailable, place N/A in the blank.)
Part A.
1. Project Name P1509 22"o CLB Headquarters
2. Location of land -disturbing activity: County Onslow City or Township Camp Leleune
Highway/Street Creek Road Latitude 340 38' 57" N Longitude 77- 19' 36' W
3. Approximate date land -disturbing activity will commence: February 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Federal Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.29 acres
6. Amount of fee enclosed: $ 700 . The Express Permitting application fee is a dual charge.
The normal fee of ; simoo )er acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the
Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2.585).
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 talia.barraco0usmc.mil
Telephone [phone] x 3242 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Commanding General. MCB Camp Leieune 910 451-2212 [phone]
Name Telephone Fax Number
1005 Michael Road
Current Mailing Address Current Street Address
Camp Leje_ une NC 28547
City State Zip City State Zip
10. Deed Book No. NIA Page No. NIA 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 Leieune
Name E-mail Address
1005 Michael Road
Current Mailing Address Current Street Address
Camp Leieune NC 28547
City State Zip City State Zip
Telephone [phone] Fax Number [phone] ____

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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(b) If the Financially Responsible Party is a Partnership or other person engaging in business 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:
Name of Registered Agent
Current Mailing Address
City State
Telephone,
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(c) In 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:
Michael Baker International
Engineering Firm or other consultant
Lauren Greenfield, P.E.
[e-mail]
E-mail Address
[phone] 412-375-3980
Individual contact person (type or print) Telephone
Fax Number
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 PWD Civil Engineer
Type or print name Title or Authority
c.t... - Qily'i;fi ZZ
Signature Date
I, �G a Notary Public of the County of [r u.1U"b
State of North Carolina, hereby certify that ac� '+`�L�A�'- appeared personally
before me this day and being duly sworn acknowledged that the above forh was executed by him.
Witness my hand an, rl11t 1, this day of 20 a k
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Notary
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