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HomeMy WebLinkAboutNCC232962_FRO Submitted_20231002 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 phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Soldier Support Center WM Replacement 2. Location of land-disturbing activity: County Cumberland City or Township Fort Liberty Nnmrendy Rd.All American Freeway,ZahllnalryRd,Ohrlen 35.139 -78.999 Highway/Street Latltude(decimal degrees) LongitUde(declmel degrees) 3. Approximate date land-disturbing activity will commence:August 5, 2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Military/Utility 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.92 6. Amount of fee enclosed: $500 . 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❑ Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: NameJeremy George E-mailAddressJeremy.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 Phone: Office# Mobile# Current Mailing Address 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.) If the company is a sole proprietorship or if the landowner(s)is an individual(s), the name(s)of the owner(s)maybe listed as the financially responsible party(ies), Old North Utility Services, Inc. Adam.Loughman@asusinc.com Company Name E-mail Address P.O. Box 73316 2941 Logistics Street, Building N-6307 Current Mailing Address Current Street Address Fort Liberty, NC 28307 Fort Liberty, NC 28310 City State Zip City State Zip Phone: Office# 910-495-1 31 1 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. CLS-StateCommunications@wolterskluwer.corn Name of Registered Agent E-mail Address 160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200 Current Mailing Address Current Street Address Raleigh, NC 27615 Raleigh, NC 27615 City State Zip City State Zip Phone: Office# 91 9-844-8360 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 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) (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. Timothy Loughman Utility Manager Type or print name Title or Authority Signature Date I, - .1-evk a_ t'---,"s' ! C" , a Notary Public of the County of C vviloieflaind State of North Carolina, hereby certify that `\ \A� lMCV1 (Jvl-appeared personally before me this dayand beingdulysworn acknowledged that the above form was executed byhim/her. 9 Witness my hand and notarial seal, this (Q day of U l , 20 (i2 1 (OAPS— Notary Seal �� 11161 �Z My commission expires oi Nota�tra .Pub Cumberaand County North Carolina Commiaston Expires 11 1;. .{y.. 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 Zip 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 9 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 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#