NCC223862_FRO Submitted_20221201

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 address or prone
number is unavailable, place N/A in the blank.)
Part A.
Proiect Name Fort Fisher State Historic Site Visitors Center
2. Location of land-disturbina activity: County New Hanover City or Township Kure Beach
Fort Fisher Blvd S 33.97183-7791762
Highway/Street Latltude(decimal degrees) LOngltude(decimal degrees)
3
4.
5.
Approximate date iand-disturbing activity will comm
Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9 18
6. Amount of fee enclosed: $ 1 ,000 . 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.
7. Has an erosion and sediment control plan been filed'! Yes [xl Enclosed ❑ No ❑
8. Person to contact should erosion and sedimen'L col ,Lrol issueb arise during land -disturbing activity:
NameTony Romaine E-mail Address [e-mail]
Phone: Office # 919-814-6614 Mobile # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
State of NC, Dept of Natural & Cultural Resources 919-814-6800 n/a
Name Phone: Office # Mobile #
4605 Mail Service Center 109 East Jones St.
Current Mailing Address Current Street Address
Raleigh, NC 27699-4605 Raleigh, NC 27601
City State
Zip City
10. Deed Book No. n/a Page No. n/a
State
Zip
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 party(ies).
State of NC Dept of Natural & Cultural Resources Tony. [e-mail]
Company Name
4605 Mail Service Center
Current Mailing Address
RalAiryh NIC'.77Rgq-ARn.q
City State
Phone: Office # 919-814-6614
E-mail Address
109 East Jones St.
Current Street Address
Raleigh, NC 27601
Zip City State
Mobile # n/a
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, dive 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
Phone: Office #
E-mail Address
Current Street Address
State Zip 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.
Tony Romaine Construction Project Manager
Type print name
Signature
Title or Authority
A01
�
Date
I, I I14��og U. a Notary Public of the County ofy" 1`11
State of North Carolina, hereby certify that ( G ppeared personally
before me this day and being duly sworn acknowledgedhat the above form was executed by him/her.
ell
Witness my hand and notarial seal, this day of 14 20
C,
0'�'� Notary22-
J" •/
Comm. Exp. My commission expires / �' r+
10-22--024.

Continued from Items 9 & 10 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 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:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zia City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 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 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
Current Mailing Address
E-mail Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
Company 3 Name
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 #