NCC220409_FRO Submitted_20220120

DocuSign Envelope ID: FK3HEB-71334-43EA-91BF-310FA44FDC7B
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. Lake Orange CIP - Project 1 - Erosion Control Barrier Replacement
1. Project Name
2. Location of land -disturbing activity: County Orange City or Township Cedar Grove
3
4
Highway/Street Lake Orange Rd. Latitude 36.147924
Longitude -79.148838
Approximate date land -disturbing activity will commence: To Be Determined (est. June 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Dam Rehabilitation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.54 acres
6. Amount of fee enclosed: $ 325.00 . 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 Christopher J. Sandt, P.E. E-mail Address [e-mail]
Telephone [phone] cell # 512-590-0359 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Orange County, North Carolina 919-245-2575 919-644-3002
Name Telephone Fax Number
P.O. Box 8181 131 W. Margaret Lane, Suite 201
Current Mailing Address Current Street Address
Hillsborough, NC 27278 Hillsborough, NC 27278
City State Zip City State Zip
10. Deed Book No. 212 Page No. 359-361 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Orange County, North Carolina [e-mail]
Name E-mail Address
P.O. Box 8181 300 W. Tryon Street
Current Mailing Address Current Street Address
Hillsborough, NC 27278 Hillsborough, NC 27278
City State Zip City State Zip
Telephone [phone] Fax Number 919-644-3002

DocuSign Envelope ID: F3EV9EB-71334-43EA-91 BF-310FA44FDC7B
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
E-mail Address
Current Mailing 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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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.
Bonnie Hammersley County Manager (Orange County, NC)
Type or print n
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Me or Authority
1/28/2021
ure / ) Date
I, ���, S.SC. 6� �il 15��, a Notary Public of the County of �GM
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State of North Carolina, hereby certify that appeared
personally before me this day and being duly sworn acknowledged that the ab e form was
executed by him.
Witness my hand and notarial seal, this abl-13- day of r--),(vvu )(��,,, 20
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DocuSign Envelope ID: HEYKB-71334-43EA-91 BF-310FA44FDC7B
ORANGE COUNTY —DEPARTMENT USE ONLY
Party/Vendor Name: Orange County Party/Vendor Contact Person: Christopher J. Sandt, P.E. Contact Phone: 919-
245-2583 Party/Vendor Address: 131 W. Margaret Lane (PO Box 8181) City Hillsborough State: NC Zip: 27278
Department: Planning Amount: $0 Purpose: Bonnie Hammersley original signature and notarization of Financial
Responsibility Form, for pending Lake Orange CIP erosion control review submission to NCDEMLR Budget
Code(s): 61370035-850000-10075 (Lake Orange Dam Rehabilitation CIP — Land & Assoc. Costs) Vendor # (N/A
if new vendor) Vendor is a BOCC consultant? Yes ❑ No® Contract Type: (Check one) New ❑ Renewal ❑
Amendment ❑ Effective Date Approved by Board Yes❑ No❑ Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
Department Director's Signature (,° o 15.kd
Date: 1/22/2021
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer
Risk Management
Date:
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Q..... u o 1/22/2021
Office of the Risk Management Officer FES. , Date:
Financial Services
This instrument has been pre -audited in the manner required by the Local Government Budget and Fiscal Control Act:
1/22/2021
Office of the Chief Financial Officer rg t, Date:
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney 3-1-1 b"ta
Clerk to the Board
Date: 1/28/2021
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: [e-mail]
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board
Revised 07/20
Date: