NCC222355_FRO Submitted_20220712

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1 . Project Name RECAPITALIZE USCG STATION FORT MACON STATION FORT MACON ATLANTIC BEACH, NC
2. Location of land -disturbing activity: County CARTERET City or Township ATLANTIC BEACH
E Fort Macon Road 34.696760-76.681035
Highway/Street _ LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: July 29, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Federal Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.27 acres
6. Amount of fee enclosed: $ 300.00 . 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 0 Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Hugo Adams E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
United States Coast Guard 757-852-3400
Name
5505 Robin Hood Road, Suite K
Current Mailing Address
Phone: Office #
Mobile #
5505 Robin Hood Road, Suite K
Current Street Address
Norfolk, VA 22513-2431 Norfolk, VA 22513-2431
City State Zip City State Zip
10. Deed Book No. Military Base Page No. Multiple 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Haskell c/o Bradford Slappey
Company Name
111 Riverside Avenue
[e-mail]
E-mail Address
111 Riverside Avenue
Current Mailing Address Current Street Address
Jacksonville, FL 32202 Jacksonville, FL 32202
City State Zip City State Zip
Phone: Office # 904-791-4524 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:
Cogency Global, Inc N/A
Name of Registered Agent E-mail Address
212 South Tryon Street, Suite 1000 212 South Tryon Street, Suite 1000
Current Mailing Address Current Street Address
Charlotte, NC 28261 Charlotte, NC 28261
City State Zip City State Zip
Phone: Office # 866-621-3524 Mobile #
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:
N/A
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 company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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.
Bradfo
Executive Vice President
Type rint na Title or Authority
ZZ-
Signa a YDate
wk�rk, -,a Notary Public of the County of DUV A-r,
Oak !
State of "'--t o:: , hereby certify that t3ir'-Ad;&►d SJGt-aIp" appeared personally
before me this day and being duly sworn acknowledged that the above fob rrm was executed by him/her.
Witness my hand and notarial seal, this J#k day of �/ , 20.0,_
sKARIAJ. NEWKIRK Notary
COMMMW # GG 343157
a., 4: rss June 9, 2023 O
«��''' 6OnWT TmyF*hwM7019 My commission expires ! / "�--_