NCC220746_FRO Submitted_20220216

FINANCIAL
SEDIMENTATION POLLUTION CONTROL ACT
Noroved by
person mayinitiate any land-disturbing activity on one or
me acres as covered have been completedy he Act and and approved fore this
form and an acceptable erosion and sedimentation controlplan form to the
d!
the Land Quality Section, N.C. Department of Environmental Quality. Submit the completed
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail an
or fax information unavailable, place N/A in the blank.)
Part AP BLRI 2D17- Blue Ridge Parkway, Laurel Fork Bridge Replacement at MP 248.85
1. Project Name n/a
2. Location of land-disturbing activity: County Ashe City or Township81 � 15' 37"
Blue Ridge Parkway Latitude 36° 23' 1 7"
Highway/Street Longitude
3. Approximate date land-disturbing activity will commence:
March 2022
Public Recreation
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3,9
6. Amount of fee enclosed: $ 400'00 . 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 X No Enclosed
X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Jonathan Woody E-mail Address jonatl'[e-mail]
Telephone [phone] Cell # 865-312-3616 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Federal Government 828 348-3400
Name Telephone Fax Number
Blue Ridge Parkway/ NPS 199 Hemphill Knob Rd
Current Mailing Address Current Street Address
Asheville, NC 28803
City State Zip City State Zip
10. Deed Book No. NA Page No. NA 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.
Federal Highway Administration [e-mail]
Name E-mail Address
22001 Loudoun County Parkway Building E2 Suite 200
Current Mailing Address Current Street Address
Ashburn VA 20147
City State Zip City State Zip
Telephone [phone]
P Fax Number

2. onsiblelinaA9 Parryent; is not a resident of North
Carolina, give name and street address
a) Financially Resp
of( the!fthe designated North Caro n/a
National Park Service E-mail Address
Name
199 Hemphill Knob Rd Current Street Address
Current Mailing Address Zip
C
Asheville, N 28803 State
State Zip City
City 48-3400 Fax Number n a
Telephone
828 3
erson engaging in bus�neResponsible
assumed If the Financially Responsible Party
is a Partnership or other p If the Financially
of the Certificate of Assumed ame
Party name,
attach a copy Agent:
Corporation, give name and street address of the Registered
is a Corpora
NSA E-mail Address
Name of Registered Agent
Current Street Address
Current Mailing Address
State Zip
City
State Zip City
Fax Number
Telephone
the best of my knowledge and belief and was provided al
The above information is true and correct to t with
must be signed by the Financially Responsible Person if an inddn ►
by me under oath (This form g artner, or registered agent or his attorney-in-fact, or if not an individual, by an officer, director, p I agree to nt with
ri to execute instruments for the Financially Responsible Perseodn). I
e
the authority
corrected information should there be any change in the information prove
n.
Ryan Kimberley
Employee of the US Government, FHWA
Type or print name Title or Authority
91fAbAJA7
Signatu Date
I, SOk \ 3 , a Notary Public of the County of \ \ \ \Y-N
Com s# # \i‘ hereby certify that V Kr\t"'W(`�''C\ appeared
personally before me this day and being duly sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this '\C' day of Xr , 20 ?.\
LISA TH LANQERS
NOTARY PUBLIC
REGISTRATIONAXTON 7341694 �]s C�Jn
COMMONWEALTH OF YIRG9INIA
MY COMMISSION EXPIRES Notary
wI JUNE 30, 2022
My commission expires ..N.jr ��