NCC232522_FRO Submitted_20230822

Check if this project is ARPA-funded ❑
Attach a copy of the Letter of Intent to Fund
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Chemserve Tanks 9-12
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g, SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
2. Location of land-disturbing activity: County New Hanover City or Township Wilmington
River Rd 34.1833 -77.9528
Highway/Street Latitude(decimaldegrees) Longitude(decimaldegrees)
3. Approximate date land-disturbing activity will commence:8/21/23
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '70
6. Amount of fee enclosed: $200'00 . 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 0 Enclosed 0 No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Matthew Law E-mail [e-mail]
Phone: Office# 757-544-0784 Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Chemserve Terminal of Wilmington, LLC 910-799-0180 757-544-0784
Name Phone: Office# Mobile#
3325 River Rd 3325 River Rd
Current Mailing Address Current Street Address
Wilmington, NC 28412 Wilmington, NC 28412
City State Zip City State Zip
10. Deed Book No.5831 Page No.695 Provide a copy of the most current deed

(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.
Matthew L Vice President
Typ or nt na Title or Authority
8/21/23
ig atur Date
kke_1c -1-eX , a Notary Public of the County of Nc_i-- rj-{gn 1ey'
1
State of North Carolina, hereby certify that Ao_it , appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my han`�tand notarial seal, this Z day of �uu`S� , 20 23
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