NCC221921_FRO Submitted_20220520

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. Randolph Road Industrial Park Sewer
1. Project Name p
2
Location of land -disturbing activity: County Cleveland
City or Township Shelby
Highway/Street Randoiph Road (SR 1308) Latitude 35.308827 _ Longitude-81.595755
3. Approximate date land -disturbing activity will commence: January 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.) Industrial -utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas) 3.05
6. Amount of fee enclosed: $.260 . 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 Enclosed X
8 Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name RJ MOZeley E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
City of Shelby
Name Telephone Fax Number
300 S. Washington Street 300 S. Washington Street
Current Mailing Address Current Street Address
Shelby, NC 28150
City State Zip City State Zip
10. Deed Book No. 1710 Page No. 0560 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
Rick Howell [e-mail]
Name E-mail Address
300 S. Washington Street 300 S. Washington Street
Current Mailing Address Current Street Address
Shelby, NC 28150 Shelby, NC 28150
City State Zip City State Zip
Telephone [phone] Fax Number 704-484-6871

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
Telephone.
E-mail Address
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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Rick Howell
Type o 1" t name
Siam e .
City Manager, City of Shelby
Title or. Auth rity
Date
1, ��-6-yo w Vv�l1��l�1L�1 a Notary Public of the County ofbedda-
State of North Carolina, hereby certify that 0-1 G appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
1114
Witness my hand and notarial seal, this ' day of �-� , 20 1
CAROL S. WILLIAMS
Notary Publi N rth Carolina No ary
Clevelounty " V�
My Commission Expires My commission expires (j V
February08, 2024