NCC223694_FRO Submitted_20221031

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. Jacksonville Fire Station #4
1. Project Name__ _ _
2. Location of land -disturbing activity: CountyOnslow City or TownshipJacksonvIIIe
Highway/Street Marketplace ❑r• Latitude 34'47'39"N Longitude -77' 24' 12"W
3. Approximate date land -disturbing activity will commence: December 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Public/Institutional-
5- Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0 acres
6. Amount of fee enclosed: $ 400.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Nlc Lanier E-mail Addressn Ian ier@jacksonvil lenc.gov
Telephone [phone] cell # _ Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Jacksonville
Name Telephone Fax Number
PO Box 128 815 New Bridge Street
Current Mailing Address Current Street Address
Jacksonville, NC 28541 Jacksonville, NC 28540
City State
10. Deed Book No. 1045
Zip City
Page No. 63 _
State
Zip
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 Jacksonville
Name E-mail Address
PO Box 128 815 New Bridge Street
Current Mailing Address Current Street Address
Jacksonville, NC 28541 Jacksonville, NC 28540
City State Zip City State Zip
Telephone _ Fax Number N/A

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
Tel
E-mail Address
Current Street Address
State Zip 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
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.
Ronald F. Massey
Type or print name
Signature
Deputy City Manager
Title or Authority
9/16/2022
Date
1, Alexl S ZcmP.c,.nLV__ a Notary Public of the County of (ins k o \,t _
State of North Carolina, hereby certify that CZonrxL c) F . MGiSs c.1 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 201 day of Sc_p\-c_m\C c r- 20 22--
ALE= ZAMECNIK
_* ruiuc My o" Expires�•t7
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My commission expires MarGln 2.3 , 2-07_"1