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HomeMy WebLinkAboutNCC216452_FRO Submitted_20211118Print Form SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department NATURAL - 115 West Main Street, Lincolnton, NC 28092 704-736-8501 Fax: 704-736-8504 RPSOifRCfS FINANCIAL RESPONSIBILITY / OWNERSHIP FORM 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 has been completed and approved by the Lincoln County Natural Resources Department. (Please type or print. 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 UNOX Expansion 2 3 4 5 Location of land -disturbing activity: Latitude35.466944 Long itude-81.007972 Parcel Identification Number (PIN)91411 & 91413 Watershed Areallone Highway/Street Address987 Airlie Parkway Denver, NC 28037 Approximate date land -disturbing activity will commence:7/1/21 Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial Total acreage disturbed or uncovered (including off -site borrow and waste areas):7.42 6. Amount of fee enclosed: $1600 . The Standard Permitting application fee of $200.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: 9 acres total $1,800). The Express Permitting application fee is a dual charge. The normal fee of $200.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total $3,800.00). 7. Has an erosion and sediment control plan been filed? Yes No EnclosedX E 10 11 Local appointed person to contact should erosion and sediment control issues arise during land -disturbing activity: NameTracy Reitzell E-mail Addresstreitzell@denverconstruction.com Telephone704-489-0232 Cell # Landowner(s) of Record (attach accompanied page to list additional owners): Fax # 704-483-1137 UNOX Inc Name Telephone Fax Number 987 Airlie Parkway 987 Airlie Parkway Current Mailing Address Current Street Address Denver NC 28037 Denver NC 28037 City State Zip City State Zip Deed Book No.2615 Page No.798-800 most recently filed in Lincoln County Register of Deeds. 2615 801-803 Future Landowner(s) if applicable: (attach accompanied page to list additional owners): N/A Name Telephone Fax Number Current Mailing Address Current Street Address City State Zip City State Zip SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department NATURAL - 115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: 704-736-8504 RPSOifRCfS FINANCIAL RESPONSIBILITY / OWNERSHIP FORM Part B 1. 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): Name Current Mailing Address City Telephone E-mail Address Current Street Address State Zip City State Zip Fax Number 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 State Zip Telephone 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 Current Mailing Address City State Telephone E-mail Address Current Street Address Zip City State Fax Number Zip (c) In order to facilitate Permitting, it is necessary to be able to contact the Engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: CES Group Engineers LLP scoldren@ces-group.net Engineering Firm or other consultant E-mail Address 274 N Hwy 16 Business, Suite 300 Denver INC 28037 Current Mailing Address City State Zip Sean Coldren 704.489.1500 N/A Individual contact person (type or print) Telephone Fax Number SOIL EROSION and SEDIMENTATION CONTROL Lincoln County Natural Resources Department NATURAL 115 West Main Street, Lincolnton, INC 28092 704-736-8501 Fax: 704-736-8504 RC50GRC[5 FINANCIAL RESPONSIBILITY / OWNERSHIP FORM (d) Contractors and/or Subcontractors (person(s) or firm(s) engaging in the land -disturbing activity Denver Construction Company Name of Person or Firm Name of Person or Firm P.O. Box 1169 Current Mailing Address Current Street Address Denver INC 28037 City State Zip City State Zip Tracy Reitzell Individual contact person (type or print) Individual contact person (type or print) 704-489-0232 Telephone Telephone Fax Number704-483-1137 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 by any change in the information provided herein and any other associated documents. I understand that all documents that are associated with this project and project number are parts of the complete project document. Permission to Enter on Land I certify that I am authorized to grant and do in fact grant permission to the Natural Resources Erosion Control Inspector and his agents to enter on the land in question in connection and/or related to this permit. Type or print name Signature Title or Authority Date I, , a Notary Public of the County of State of North Carolina, hereby certify that 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 day of 120 Seal Notary My commission expires