NCC223108_FRO Submitted_20220907

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name Fort Bragg Gun Pad Rehabilitation, FA-80005-21
2
Location of land -disturbing activity: County Cumberland
City or Township Fort Bragg
Hurst Drive 35.1633-79.0267
Highway/Street Latitude;decimal degrees} Long itude(decimal degrees)
3. Approximate date land -disturbing activity will commence:August 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.1 8
6. Amount of fee enclosed: $70Q+200=900 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameLee Ward E-mail [e-mail]
Phone: Office # (9 1 0) 908-5286 Mobile It
Landowner(s) of Record (attach accompanied page to list additional owners):
Department of Defense
Name
Current Mailing Address
City
Phone: Office # Mobile #
Current Street Address
State zip 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 partyfts).
Fort Bragg Directorate of Public Works, Aaron Brown
Company Name
2175 Reilly Road Stop A
Current Mailing Address
Fort Bragg, NC 28310-5000
aaron.s. [e-mail]
E-mail Address
4300 Butner Road
Current Street Address
Fort Bragg, NC 28310
City State Zip City State Zip
Phone: Office # [phone] 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 of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
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.
Lee Ward
ZType o rint na e
Chief, DPW/Water Management Section
Title or Authority
/1 s 1,, 2a2Z
Date
a Notary Public of the County of
State of North Carolina, hereby certify that 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 day of , 20
Notary
My commission expires.