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HomeMy WebLinkAboutNCC240860_FRO Submitted_20240326 Check if this project is ARPA-funded ❑ 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, including any activity under a common plan of development of this size as covered by the NCGO1 permit, 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 Discount Tire - New Bern, NC *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Craven City or Township New Bern Highway/Street U.S. Hwy 17 Latitude(decimaldegrees)35.096746 Long ltude(decimaldegrees) 77100578 3. Approximate date land-disturbing activity will commence:2/1/2023 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 '4 6. Amount of fee enclosed: $200 . The application fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is$900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes❑x Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Kelly Wagoner E-mail Address kwagoner@fg-inc.net Phone: Office# 770-368-1399 Mobile# 770-500-4973 9. Landowner(s) of Record (attach accompanied page to list additional owners): Halle Properties, L.L.C. 480-606-6000 Name Phone: Office# Mobile# 20225 N Scottsdale Rd 3601 ML King Jr. Blvd Current Mailing Address Current Street Address Scottsdale, AZ 85255 New Bern, NC 25862 City State Zip City State Zip Page No.2146-2150 10. Deed Book No. 3744 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)maybe listed as the financially responsible party(ies). Halle Properties, L.L.C. construction@discounttire.com Company Name E-mail Address 20225 N Scottsdale Rd Same as mailing address Current Mailing Address Current Street Address Scottsdale, AZ 85255 City State Zip City State Zip Phone: Office# 480-606-6000 Mobile# 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Name of Individual to Contact(if Registered Agent is a company) (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: Corporation Service Company danielle.faust@cscglobal.com Name of Registered Agent E-mail Address 2626 Glenwood Ave, Suite 550 Same as mailing address Current Mailing Address Current Street Address Raleigh, NC 27608 City State Zip City State Zip Phone: Office# 800-927-9800 Mobile# Danielle Faust Name of Individual to Contact(if Registered Agent is a company) (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 th 'nformation provided herein. Bridget Kautzky , Real Estate Type r print name Title or Authority It 'I • Signatur Date I, c.,'1RA \'eft , a Notary Public of the County of P4G Ccpri State of itaa, hereby certify that LU€ • 4 Au)rLk appeared personally before me this day and being duly sworn acknowledgedK that the above form was executed by him/her. Witness my hand and notarial seal, this irt4, day of Co 6>:.;?— , 20:2(3 WARNER /�/� -✓��c.-�1�,eiL� , DONNA M;.��;„ Notary Notary Public i- pv42 oa` Maricopa County,Arizona My Comm.Expires 04-06-24 .�G, D Commission No.581521 My commission expires