NCC220987_FRO Submitted_20220309

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 11192021
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. Shelby Rail Trail - Phase 1
1. Project Name
2. Location of land -disturbing activity: CountyClevelanU City orTownshipShelby
Highway/Street200 W Marlon StLatitude35.2921 92 Longitude 81.542062
3. Approximate date land -disturbing activity will commence:AS Soon AS Permit IS Received
4. Purpose of development (residential, commercial, industrial, institutional, etc.): M U n ICI pal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):4.6
6. Amount of fee enclosed: $1 , 750 . The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
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 Ben Yarboro
E-mail [e-mail]
Telephone[phone] Cell #
Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attachment
Name
Telephone Fax Number
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) 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.
City of Shelby
[e-mail]
Name
E-mail Address
P.O. Box 207
300 S Washington St
Current Mailing Address
Current Street Address
Shelby, NC 28151
Shelby, NC 28151
City State Zip
City State Zip
Telephone [phone]
Fax Number 704-484-6808

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:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
(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:
Rick Howell - City Manager
Name of Registered Agent
P.O. Box 207
Rick. [e-mail]
E-mail Address
300 S Washington St
Current Mailing Address Current Street Address
Shelby, NC 28151 Shelby, NC 28151
City State Zip City State Zip
Telephone[phone] Fax Number 704-484-6871
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
TGS Engineers acochrane [e-mail]
Engineering Firm or other consultant E-mail Address
Andrew H. Cochrane, PE 704-476-0003 ext 317 704-476-0024
Individual contact person (type or print) 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
instruments for the Financially Responsible Person). I agree to provide corrected information should there be
any change in the information provided herein.
d
9 rA
Type or .n ame Title or Althority
Signatur Date r
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I, CA VD I J' \41 1)160� a Notary Public of the County of I e-Ve-laY� d
State of North Carolina, hereby certify that 1 C� 4twt( I 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 day of J mtt 20
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Notary
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Notary Publi e orth Carolina �� �g 0
Cleveland County My commission expires 3
My Commission Expires
February 08, 2024