NCC222449_FRO Submitted_20220707

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name DPW Complex Water Main Replacement
2. Location of land -disturbing activity: County_Cumberiand City or Township Fort Bragg_
Highway/Street_Reiily Street & Butner Road_ Latitude(deaimaldegrees) _,35.96o- Long itude(decimal degrees) -79.004
3. Approximate date land -disturbing activity will commence: July 15, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Military/Utility.
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.45
6. Amount of fee enclosed 1,750 The Express Permitting application fee is a dual
charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the
Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeremy George Email Address [e-mail]
Phone: Offce # 910-495-1311 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_Department of Defense
Name Phone: Office # Mobile #
Current Mailing Address
City State Zip
Current Street Address
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.
Company Name
_P.O. Box 73316
Current Mailing Address
Fort Bragg NC_28307
City State Zip
Phone: Office # 910-495-1311
[e-mail]
E-mail Address
_2941 Logistics Street, Building N-6307
Current Street Address
Fort Bragg NC 28310
City State Zip
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 ofthe 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 NC27615
City State Zip
Phone: Office # 919-844-8360
Raleigh NC27615
City State Zip
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 Caroiina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State ,Zip
(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
(d) If 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;
_ASUS, Inc.
Engineering firm or other consultant
Isaiah Koonce
I—ndividual contact person (type or print)
[e-mail]
E-mail Address
Phone: Office #
_91 Q-366-2457
Mobile #
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 Lou hman _Utility Manager
Type or print name Title or Authority
Signature U _ Date
------------------------- -..------------- ,.----------------------------- ------------------------------------------------__------------
I, E j t o CA_ , a Notary Public of the County of (11M � �;WI &M
State of North Carolina, hereby certify that I t6 V)14 1 yJA tj1lDjeAo appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this f5
Seal
day of JUt nt , 20E?__
t4vb-"
Notary
My commission expires__LL�2ty

Continued from Items 9 & 90 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 #
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 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 #