NCC223971_FRO Submitted_20221213

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 Environment and Natural Resources. (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.
1. Project Name Middlesex Shell #2
2. Location of land -disturbing activity: County Nash City or Township Middlesex
Highway/Street Middlesex Corporate Pkwv Latitude 35.7917 ° N Longitude 78.1837 ° W
3. Approximate date land -disturbing activity will commence: June 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8.80 Ac
6. Amount of fee enclosed 585.00. 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address kvarnell(@stocksengineering.com
Telephone [phone] Cell # 252-382-0012 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nash County 252-462-0012 252-459-8197
Name Telephone Fax Number
120 W Washington Street, Suite 104 120 W Washington Street, Suite 104
Current Mailing Address Current Street Address
Nashville NC 27856 Nashville NC 27856
City State Zip City State Zip
10. Deed Book No. 2480 Page No. 268 (Provide a copy of the most current deed.)
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Nash County ionathan.boone(o)nashcountync.ciov
Name E-mail Address
120 W. Washington St. 120 W. Washington St.
Current Mailing Address Current Street Address
Nashville NC 27856 Nashville NC 27856
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
E-mail Address
Current Street Address
City State Zip City
Telephone 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
print name
Signature
Date
Public Facilities and Utilities Director
Title or Authority
I �nn lcc_ �daw► , -,a Notary Public of the County of
State of North Carolina , hereby certify that . k'-L►&
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him
'fWitness my hand and notarial seal, this day of Sex � 111 e_ _ 2022.
r r — —
JANICE EVANS Notary
Seal NOTARY PUBLIC
HALIFAX COUNTY, N. My commission expires