NCC215416_FRO Submitted_20210930

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Murray Basin Sanitary Sewer Project
1. Project Name
2. Location of land -disturbing activity: County Catawba City or Township Hickory
Highway/Street Refer to plans Latitude Longitude
3. Approximate date land -disturbing activity will commence: Summer 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): No development; building
pump stations, sewer force main and gravity sewer line 17 acres
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 1,105 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matthew Shultz E-mail Address [e-mail]
Telephone [phone]
Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
City of Hickory
828-323-7427 828-322-1405
Name
Telephone Fax Number
PO Box 398
1441 9th Ave., NE
Current Mailing Address
Current Street Address
Hickory NC
28603
Hickory NC 28601
City State
Zip
City State Zip
See attached
10. Deed Book No.
Page No.
Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who
are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible
parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager may
be listed as the financially responsible party.
Shawn Pennell
[e-mail]
Name
E-mail Address
PO Box 398
1441 9th Ave., NE
Current Mailing Address
Current Street Address
Hickory NC
28603
Hickory NC 28601
City State
Zip
City State Zip
828-323-7427
Telephone
Fax Number828-322-1405

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number.
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
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instrument nancially Responsible Person). I agree to provide
corrected information should ther in the information provided herein.
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Type or print name
Signature
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I TAtle orAuthority
Date
I, a&
, a Notary Public of the County of A�r—&
State of North Carolina, hereby certify that ICY _ !�/�P� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 19 day of , 20 ZQ
t3arlc" ,"ounty, North Carolina 'Ova 61
ejiicj-j:ary Public Notary
'. �isy ZavalaVazquez My commission expires,