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HomeMy WebLinkAboutNCC223646_FRO Submitted_20221025FINANCIAL 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 Red Ramp Area Water Main Replacement 2. Location of land -disturbing activity: County_Cumberland_ City or Township_Fort Bragg, Highway/StreeLHurst Drive, Access Road and Pratt Street Latitude(dechal degrees) - 35.160 Longitude(dechal degrees)-79.018_ 3. Approximate date land -disturbing activity will commence: November 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):9.55_ 6. Amount of fee enclosed _3,000_, 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 0 Enclosed © No 0 8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity: Name Jeremy George %nail Address,-_ _,;Jeremy. George@asusinc.com Phone: Office #910-495-1311 Mobile # 910-489-8862 9. Landowner(s) of Record (attach accompanied page to list additional owners): _Department of Defense Name Current Mailing Address City State Zip Phone: Office # Mobile # Current Street Address City State Zip 10. Deed Book No. I I Page No. Provide a copy of the most curreht 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 party(ies). Old North Utility Services, Inc. Company Name _P,O. Box 73316 Current Mailing Address Fort Bragg NC 28307 City State Zip Phone: Office # 910-495-1311 _Adam.Lougnman@asusinc,com E-mail Address „2941 Logistics Street, Building N-6307 Current Street Address Fort Bragg . NC 28310 City State Zip 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: National Registered Agents, Inc. Name of Registered Agent 160 Mine Lake Ct Ste 200 Current Mailing Address Raleigh NC 27615_ City State Zip Phone: Office # _919-844-8360 _CLS-StateCommunications@wolterskluwer, com E-mail Address 160 Mine Lake Ct Ste 200 _ Current Street Address Raleigh NC27615 City State Zip Mobile # Jean Malcomson, Assistant Secretary 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: 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 (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) —Isaiah.koonce@asusinc.com 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 L—,& -4- L� iD k 3�ZZ —Signature' V _ Date I, IT-OCI- CaDIDS _,a Notary Public of the County of lJAVY1UM(Aw/ State of North Carolina, hereby certify that 1l VP0.4)1%1 1 _00 ayl appeared personally before me this day and being duly sworn acknowledged th t the above form was executed by him/her. Witness my hand and notarial seal, this � day of OC`�)Qt f , 20 Z`7_ Seal Notary Pubic Cumberland County LCOMM ission ExPir s 11 1 2025 WrV_1 12aV--..___ Notary My commission expires n—1 is _ Zo-Z iJS" Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Name Current Mailing Address City State Zip Phone: Office # Mobile # Current Street Address City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Name Current Mailing Address City State Zip Phone: Office # Mobile # Current Street Address City State Zip Deed Gook No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Current Mailing Address City State Zip Phone: Office # Mobile # Current Street Address 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 Zip City State Zip Deed Book No. Page No.. Provide a copy of the most current deed. Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip Phone: Office # Company 3 Name 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 City State Zip Phone: Office # Current Street Address City State Zip Mobile # Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile #