NCC220796_FRO Submitted_20220217

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.
1. Project Name 2017B Water System Improvements
2. Location of land -disturbing activity: County Granville City or Township Oxford
Highway/Street
Latitude
Longitude
MLK Jr Ave
36°18'07.85"N
78°35'05.01"W
Hillsboro St
36°18'29.47"N
78°35'45.49"W
Raleigh St
36°17'31.82"N
78°34'21.04"W
Old Warehouse Sq
36'18'42.01"N
78°35'22.58"W
Old Warehouse Sq
36'18'44.30"N
78°35'22.44"W
W Thorndale Dr
36'18'17.44"N
78°36'21.90"W
Country Club Dr
36°18'17.82"N
78'36'14.61"W
Pine Tree Dr
36'18'13.97"N
78'36'10.99"W
Pine Tree Rd
36'18'18.04"N
78°36'05.71"W
E Dale Dr
36°18'03.67"N
78'36'10.77"W
Ward A\,e
36°18'06.48"N
78°36'07.96"W
Woodson St
36°19'27.91"N
78°36'05.57"W
Seaman St
36'18'10.16"N
78°36'04.29"W
3. Approximate date land -disturbing activity will commence: Summer 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Utility System -
Water Line Replacement
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.4 ac
6. Amount of fee enclosed: $390. 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Bill Roark, PE, McGill Associates E-mail Address [e-mail]
Telephone [phone] Cell # 919-338-6615
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
N/A
Name
Current Mailing Address
Telephone
Current Street Address
Fax Number
City
State Zip City
State
Zip

10. Deed Book No. N/A Page No. N/A 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.
City of Oxford Ala n.Thorntona-oxfordnc.org
Name E-mail Address
PO Box 506 300 Williamsboro Street
Current Mailing Address Current Street Address
Oxford North Carolina 27565 Oxford North Carolina 27565
City State Zip City State Zip
Telephone [phone] Fax Number
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 E-mail Address
Current Mailing Address
City
Telephone
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 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.
M. Alan Thornton
Type or print name
"--, . ✓ l�
Signature
City Manager
Title or Authority
Date
I, ��, r-��� ��- �'�r�; �� , a Notary Public of the County of r,s', t �P-
State of North Carolina, hereby certify that (�. �IG� 1 hor,���_ 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 J4 03 day of vS� , 20 ab
Notary
Seal
My commission expires a.oa
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