NCC216533_FRO Submitted_20211206

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. Town of Belville NC-133 Multi -Use Path
1. Project Name
2. Location of land -disturbing activity: County Brunswick City or Township Belville
Highway/street NC-133 Latitude 34.2026 Longitude-77.9807
3. Approximate date land -disturbing activity will commence- March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Linear Path
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.85(2)
6. Amount of fee enclosed: $ 130 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 __ —No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Athina Williams E-mail Address town [e-mail]
Telephone [phone]
Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT 910-341-2000
Name
5501 Barbados Blvd
Current Mailing Address
Castle Hayne NC
City State
10. Deed Book N
28429
Zip
Telephone
5501 Barbados Blvd
Current Street Address
Castle Hayne NC
City
State
Fax Number
28429
Zip
Page No. 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.
Town of Belville [e-mail]
Name E-mail Address
63 River Road 63 River Road
Current Mailing Address Current Street Address
Belville NC 28451 Belville NC 28451
City State
Telephone [phone]
Zip
City State
Fax Number 910-371-2474
Zip

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:
N/A
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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:
N/A
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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.
Athina Williams Town Manager
Type or print name Title or Authority
\b-20�2 t
Signature Date
I, J AGlron A. a Notary Public of the County of 13rL4-,s:'.; "c_k
State of North Carolina, hereby certify that Ak "r". e,G 1 k' q appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by #+m. ker.
Witness my hand and notarial seal, this 204day of Q C -+ 620 I
Sharon A Public n
Notary Public
Brunswick County Ndfary
I North Carolina, q
Commission Ex irBs�
My commission expires 4—? -ao 3