HomeMy WebLinkAboutNCC222619_FRO Submitted_20220726FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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. Wave Wash Louisburg
1. Project Name
2. Location of land -disturbing activity: County Franklin City or Township Louisburg
Highway/Street 602 S Bickett Blvd. Latitude 36.0844 Longitude -78.31
3. Approximate date land -disturbing activity will commence: 6/1 /22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.06
6. Amount of fee enclosed: $ 700.00 . The Express Permitting (EP) application fee is a
dual charge. The standard fee of $100.00 per acre (rounded up to the next whole acre) is assessed
without a ceiling amount. In addition, the EP supplemental fee is $250.00 per acre up to eight acres,
after which the EP supplemental fee is a fixed $2,000.00 (Example: 8.2 acres total is $2,900).
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 Forrest Peters E-mail Address fpeters@expresswashoperations.com
Telephone
850-225-0072 Cell # 850-225-0072 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
EXPRESS WASH PROPERTY HOLDINGS, LLC
850-225-0072
Name
Telephone Fax Number
5821 Fairview RD, STE 400
Same
Current Mailing Address
Current Street Address
Charlotte, NC 28209
Same
City State Zip
City State Zip
10. Deed Book No. 1882 Page No.
16 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.
Louisburg Express Wash, LLC
fpeters@expresswashoperations.com
Name
E-mail Address
5821 Fairview RD, STE 400
Same
Current Mailing Address
Current Street Address
Charlotte, NC 28209
Same
City State Zip
City State Zip
Telephone 850-225-0072
Fax Number N/A
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:
NIA
Name
NIA
Current Mailing Address
NIA
City State
Telephone NIA
NIA
E-mail Address
NIA
Current Street Address
NIA
Zip City State Zip
Fax Number NIA
(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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
OnSite Civil Group of the Carolinas jarrett@onsitecivil.com
Engineering Firm or other consultant E-mail Address
Jarrett M. Senkbeil 404-822-9147 nla
Individual contact person (type or print) 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.
Forrest Peters
Type or print na e
el
Sig re
Officer
Title or Authority
9/z
Date
a Notary Public of the County of We cluk-emkiLtW
State of North Carolina, hereby certify that t- C7 YYappeared 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 1V ' 20.
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