NCC220854_FRO Submitted_20220222

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.
1. Project Name_12" Public Sewer
2. Location of land -disturbing activity: County Cabrrus City or Township_Concord
Highway/Street (3622 Roberta Church Road) _Latitude(35.364718)_ Longitude (-80.635851)
3. Approximate date land -disturbing activity will commen ce:_(2/14/2022)
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_Other
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.03
6. Amount of fee enclosed: $ 65.00 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —Trey Goethals E-mail Add [e-mail]_
Telephone [phone] Cell # _731-4313068 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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):
Cleary Construction Inc.
Name E-mail Address
_2006 Edmonton Road Same
Current Mailing Address Current Street Address
Tompkinsville KY 42167_ Same Same
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:
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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:
Cleary Construction Inc.
Name of Registered Agent
2006 Edmonton Road
Current Mailing Address
_Tomkinsville KY 42167
City State Zip
E-mail Address
Same
Current Street Address
Same
City State Zip
Telephone [phone] 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.
Trey Goethals
Type or print na e
Signature
Regional Project Manager.
Title or Authority
Date
1 /25/2022
l ,t r) � W 4 ky , a Notary Public of the County of AyV,roP
VePJL4c.k G oe�l�� i s State of hereby certify that I "� appeared
personally before me this day and being duly swore acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this A5�h day of ��nua� 20 aJ,
TERRI DENISE WITTY _ r'
Notary Public -State at Large Notary
�SetJNTUCKY
My Commission Expires 110►� �d
-------- My commission expires