HomeMy WebLinkAboutNCC223341_FRO Submitted_20220926FINANCIAL 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 Macridge & Chicken Intersection Improvements, FA-20007-4
2. Location of land -disturbing activity: County Cumberland City or Township Fort Bragg.
Chicken Road 35.0936 N 79.0308 w
Highway/Street LatltUde{decimalder�rees} LOnglttlde{decimaldeflrees}
3. Approximate date land -disturbing activity will commence: October 3, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Military
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0 acres
6. Amount of fee enclosed (400 + 1000) = 4400 The Express Permitting application fee is a dual charge.
The normal fee of $1 00.00 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, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.1 0-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 21 No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Lee Ward E-mail Address lee.p.ward.civ@army.mil
Phone: Office # (91 0)908-5286
Mobile #
9. Landowner(s) of Record (attach accompanied page to fist additional owners):
Department of Defense
Name
Current Mailing Address
Phone: Office # Mobile #
..........
Current Street Address
City 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.) lithe company is 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).
Fort Bragg Dlraotoralo of Public Worhs, Aaron Brown, Deputy Director
Company Name
2175 Reilly Road Stop A
aaron.s.brown2.civ@army.mil
E-mail Address
4300 Butner Road
Current Mailing Address Current Street Address
Fort Bragg , NC 28310-5000 Fort Bragg, NC 28310
City State Zip City
Phone: office # (910) 396-7202 Mobile #
State
Zip
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
E-mail Address
Current Street Address
City State Zip City
Phone: Office # 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
Phone: Office #
E-mail Address
Current Street Address
Zip City
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:
Gradient, PLLC
Engineering firm or other consultant
Jim Reed
Individual contact person (type or print)
jreed a@gradientnc.com
E-mail Address
910.824.7731
Phone: Office # 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 Verson 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.
David A. Heins
Type or print a e
Signature
Chief, DPW/Environmental Division
Title or Authority
114LIZ-Z
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
Notary
20
tl', My commission expires