NCC223123_FRO Submitted_20220914

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 and/
or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name PORT OF MOREHEAD CITY IMPROVEMENTS TO BERTHS4&5
2. Location of land -disturbing activity: County CARTERET City or Township MOREHEAD CITY
Highway/Street113ARENDELLSTREET Latitude 34.72 Longitude -76.7
3, Approximate date land -disturbing activity will commence: October 2022
4
5.
Purpose of development (residential, commercial, industrial, institutional, etc.): INDUSTRIAL
Total acreage disturbed or uncovered (including off -site borrow and waste areas):1.50
6. Amount of fee enclosed: $ 200 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Todd C Walton E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
g Landowner(s) of Record (attach accompanied page to list additional owners):
NC STATE PORTS AUTHORITY 910-746-6460
Name Telephone Fax Number
PO Box 9002 113 Arendell Street
Current Mailing Address Current Street Address
Wilmington NC 28402 Morehead City NC 28557
City State Zip City State Zip
10. Deed Book No. 1249 Page No. 463 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.
NC STATE PORTS AUTHORITY
Name
PO Box 9002
Current Mailing Address
Wilmington NC 28402
City State Zip
Telephone [phone]
E-mail Address
113 Arendell Street
Current Street Address
Morehead City NC 28557
City State Zip
Fax Number 910-746-6430

Telephone [phone] Fax Number 910-746-6430
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:
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
Fax Number
(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
E-mail Address
Current Street Address
City State Zip City State Zip
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.
Brian E Clark Executive Director
Typ pr' a Title or Authority
I15 /Zo 2,2.1
Signature Date
r 4 1, _ a Notary Public of the County of ice ` �t
�`��"r' 4 C� BA�, �! �....
State of North Carolina, hereby certify that tlVfP1 E • appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this 13
PATRICIA M. HAMRIC
Notary Public, North Carolina
Brunswick County
M$�mmission Expires
April 10, 2026
day of 20
kotary
My commission expires q.1 • Z Lb