HomeMy WebLinkAboutNCC222070_FRO Submitted_20220604FINANCIAL 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 Countryside Acres Lots 1 - 15
2. Location of land -disturbing activity: County Sampson City or Township Belvolr
Highway/Street SR 1 832 Latitude(decimal degrees) 35.0590 Longitude(decimal degrees)-78.3873
3. Approximate date land -disturbing activity will commence: 04-01-2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.7
6. Amount of fee enclosed: $ 1000.00 . The application fee f $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10cre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Powell E-mail Addressklpl 977@yahoo.com
Phone: Office # 910-299-9146 Mobile # 910-260-2220
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cape Fear Industries USA, Inc
Name
P.O. Box 819
Current Mailing Address
Clinton NC
Phone: Office #
906 Industrial Dr.
Current Street Address
28329 Clinton NC
City State Zip City
10. Deed Book No. 2035 Page No. 694
State
Mobile #
28328
Zip
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) may be listed as the financially responsible party(ies).
Kevin Powell
Company Name
302 Martha Lane
Current Mailing Address
Clinton NC 28328
City State
Phone: Office # 910-299-9146
klp1977@yahoo.com
E-mail Address
302 Martha Lane
Current Street Address
Clinton NC 28328
Zip City State
Mobile # 910-260-2220
®:
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:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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.
Kevin Powell
Type or print name
Signature
Owner
Title or Authority
Date
I, n Q .�- a.� L U ✓mil , a Notary Public of the County of a CA w, Q"7,o I l
State of North Carolina, hereby certify that 1 \ 2\) � '^\ t PO W e, � appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my"pett ' 6'�wtarial seal,
My con .Expires
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this O,c�') day of _ 20_ �)
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