NCC220512_FRO Submitted_20220201

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 Environment and Natural Resources. (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.
Project Name Al Collie Inert Debris Landfill
2. Location of land -disturbing activity: County Nash City or Township Griffins
Highway/Street Taylors Store Road Latitude 36.0544' N Longitude 77.9729' W
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Inert Debris Landfill
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.92 Ac
6. Amount of fee enclosed 1,100.00. The application fee of $100.00 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Varnell E-mail Address kvarnella-stocksengineering.com
Telephone [phone] Cell # 252-382-0012 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sidney A. Collie, Jr. 252-544-1235 252-459-8197
Name Telephone Fax Number
5801 Taylors Store Road 5801 Taylors Store Road
Current Mailing Address Current Street Address
Nashville NC 27856 Nashville NC 27856
City State Zip City State Zip
10. Deed Book No. 1815 Page No. 932 (Provide a copy of the most current deed.)
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):
Sidney A. Collie, Jr. Iscsaca-yah00.com
Name E-mail Address
5801 Taylors Store Road 5801 Taylors Store Road
Current Mailing Address Current Street Address
Nashville NC 27856 Nashville NC 27856
City State Zip City State Zip
Telephone [phone] Fax Number 252-459-8197

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
E-mail Address
Same
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.
Sidney A. Collie, Jr. Owner
Type or print name Title or Authority
W44d W &Oe�I t161 f 210 21
Signature Date
I, T • 4'�, V.- U'8.Iu , a Notary Public of the County of
State of North Carolina hereby certify that t A • _�•,
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 2021.
EEdgeco,mhe
EVIN VARNELLotary Public Not y
fiamh Carolina County My commission expires