NCC220321_FRO Submitted_20220126

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 NIA in the blank.)
Part A. FORMER BASF PLANT SITE: DEMOLITION E&SC PLAN
1. Project Name
2. Location of land -disturbing activity: County Pender/New Hanover Wg
ilmin ton
Y tY City or Township
Highway/Street Vitamin Drive Latitude 34.334763890 Longitude -78.005230560
3. Approximate date land -disturbing activity will commence: 01 /22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 42 acres
6. Amount of fee enclosed: $ 4,200.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name Chad McEwen E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Pender County [phone] [phone]
Name Telephone Fax Number
805 South Walker Street 805 South Walker Street,
10.
Current Street Address
Burgaw NC 28425
City State Zip City State Zip
Deed Book No. 5531 Page No. 18-25 Provide a copy of the most current deed.
Current Mailing Address
Burgaw NC 28425
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 orirrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Pender County, NC Attn: Chad McEwen [e-mail]
Name
805 South Walker Street
Current Mailing Address
Burgaw NC 28425
City
State Zip
Telephone [phone]
E-mail Address
805 South Walker Street
Current Street Address
Burgaw NC w: _ 2842`5}� ::.
City Stater, w : ' Zipf-
Fax Number [phone] .
1

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:
NIA
Name
Current Mailing Address
City
E-mail Address
Current Street Address
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:
NIA
Name of Registered Agent
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone 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.
CIL4'�" C—
T e Title or Aut
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Signature Date
001n G N3 Notary Public of the County of eenc_k�r
State of North Carolina, hereby certify that CIAAL') ��, 4 t)J, M� u"' ers1appeared
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 V- , 20
\N �.
-"Not*
L/ =� �= My commission expires
_ PUBLIC