NCC223056_FRO Submitted_20220829

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 N/A in the blank.)
Part A.
1. Project Name Area B Water Main Replacement
2. Location of land -disturbing activity: County_Cumberland City or Township_Fort Bragg_
Highway/Street_Leham St, Caquiny Lp, Piquaville Ct, Sunchon Rd, Sicily Dr, Honeycutt Rd, Monteburg Rd, Manhay Rd_
Latltude(decimal degrees) _35.142_ Longltude(decimal degrees) _ 79.013_
3. Approximate date land -disturbing activity will commence: October 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): 13.21
6. Amount of fee enclosed 3,400 . 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 RI No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jeremy George Finail Address [e-mail]
Phone: Office # 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 Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

1. Company(iee) 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.
P.O.
Fort Bragg
City �tate Zip
Phone: Office # 910-495-1311
__/\dam.Lougnman@amuaincoom___
E-mo|Addreon
_C2S41 Logistics Street, Building N-G3O7
unentStreet Address
Fort Bragg NC__________
City State
NYobi|e#
Note: Ifthe Financially Responsible Party ianot the owner nfthe land tubadisturbed, 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 isadomestic company registered nnthe NC Secretary ofState
business registry, give name and street address of the Registered Agent:
National R�g�tenadAgent .|no�
_ame of Registered Agent
160 Mine Lake [%Ste 200
Current Mailing Address
_Raleigh 15__
City State Zip
Phone Dffioa# 919-844- 3GD
u
E-mail Address
1GOMine Lake Ct Ste 200
Raleigh _NC
Jean K8elcomoon.Assistant Secretary
Name of Individual to Contact (if Registered Agent is a company)
(b) Ifthe 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile #
Name ofIndividual toContact (if Registered Agent ioacompany)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company in Doing Business An. 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
Individual contact person (type or print)
[e-mail]
E-mail Address
Phone: Office #
_910-366-2457
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 Loughman _Utility Manager
Type or print name Title or Authority
A ;�'� oll'Y16_
_ Signature Ll_ Date
I, T�-Qvw_yxmkoS a Notary Public of the County of (t_ P,�i�� n�'C
State of North Carolina, hereby certify that ` t ,1�J-1 I' `' �r G��` appeared personally
before me this day and being duly sworn acknowledged th6t the abo a form was executed by him/her.
Witness my hand and notarial seal, this 1 `� day of , 20
F uIAqtA-,- P0"_j---
Notary
My commission expires 11 ' I ki. 7 I
Notar
Commission Expire 1/12025 i�

Continued from Items 9 & 90 in Part A of the Financial ResponsibilitylOwnership 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:
Phone: Office # Mobile #
Name
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:
Phone: Office # Mobile #
Name
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
City State Zip
Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part B of the Financial ResponsibilitylOwnership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
City State
Phone: Office #
Company 3 Name
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
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 #