NCC230490_FRO Submitted_20230321

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT N&T #21192
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 Scotts Hill Medical Center
2. Location of land -disturbing activity, County New Hanover City or Township Wilmington
Highway/Street 151 Scots H Of Medical Park Dr Latitude (drdMal degreeg) Longitudecdeci,,a, degfee&)
3. Approximate date land -disturbing activity will commence: As Soon as All Permits are Received
IJ
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Hospital & MOB
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 30.2 (Prev. 28.5)
Pd $2 00 (Prev. ,900)
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: 8.1 0-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes El Enclosed El No [I
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name John S. Tunstall, P.E.
Phone: Office# 910-343-9653
E-mail Address Itunstall@ ntengi neers, com
Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners);
Novant Health New Hanover Regional Medical center, LLC 704-316-4351 N/A
Name
P.O. Box 9000
City
State zip
Phone. Office # Mobile -0-
2131 S. 17th Street
Current Street Address
Wilmington, NC 28401
State
0
10. need 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 party(ies).
Novant Health New Hanover Regional Medical Center, LLC
Company Name
P.O. Box 9000
Current Mailing Address
Wilmington, NC 28402
City State
Phone: Office # 704-316-4351
[e-mail]
E-mail Address
2131 S. 17th Street
Current Street Address
Wilmington, NC 28401
Zip City
Mobile # N/A
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(cl If the Financially Reaaonsib�e Party is engaging in busineSS underan assumed narne, give name under
which the company i$ DoirEg Business As. It the Financially Responsible Party is an individual, Genefal
Partnership, or ether company not registered and doing business tinder an assi�rned name, attaeft a Copy
of the Certificate of Assumed Name_
Company DBA Name
The above information is true and correct to tl�e best of my knowledge and heiief and -,vas provided
by me under oath_ (This form must be signed by the Financially Responsible Person if an indMdual(s)
or his attorney -in -fact, or if not an individual, by are officer, director partner, or registered agent with
the authority to execute instruments fpr the Financially Responsible Party). I agree to provide
corrected information should there be any change in the information provided herein.
Matthew H. Stiene Senior Vice President of Construction & Facilities
Type or print name Title or Authority
Signa-ure Date
a Notary Public of the County cf
State of North Carolina, hereby certifythat L-nPasyt: r _.° appeared persorally
before me this day and being duly sworn acknowledged that the above farm was executed by nirnfher.
Witness my hand and notarial seal, this day of �y-20
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