NCC221252_FRO Submitted_20220406

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 and/
or fax information unavailable, place N/A in the blank.)
Part A. Martin Count Airport - Parallel Taxiwa
1. Project Name Y p Y
2. Location of land -disturbing activity: County Martin City or Township Williamston
Hiy-hway/Street 21 `�' 5 Airport Read Latitude 35d 51' 43:89" N Longitude 77d 10' 41.53" W
3. Approximate date land -disturbing activity will commence: March 2022
4 Purpose of development (residential, commercial, industrial, institutional, etc.): Airport / Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 21 AC
6 Amount of fee enclosed: $ 1,365.00 . 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Jason Elliott E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax #
9 Landowner(s) of Record (attach accompanied page to list additional owners)
County of Martin
[phone] [phone]
Name
Telephone Fax Number
P.O. Box 668
305 East Main Street
Current Mailing Address
Current Street Address
Williamston NC 27892
Williamston NC 27892
City State Zip
City State Zip
10. Deed Book No. G-8 ; J-15 page No.
623 ; 272 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.
Martin County
[e-mail]
Name
E-mail Address
P.O. Box 668
305 East Main Street
Current Mailing Address
Current Street Address
Williamston NC 27892
Williamston NC 27892
City State Zip
City State Zip
Telephone [phone]
Fax Number [phone]

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 State Zip
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:
Name of Registered Agent E-mail Address
Current Mailing Address
City
Telephone
Current Street Address
State Zip City State Zip
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.
David Bone County Manager
(7
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111as%a
Signature Date
I, S 5 a Notary Public of the County of &fih
State of North Carolina, hereby certify that 4 117#rLe_ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand ar ,%prial sea], this day of 4&mjnb 20 _
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Notary
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