NCC222547_FRO Submitted_20220726

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Sally Hills Farm Tree Clearing - Phase 2
2.
3.
4.
5.
Location of land -disturbing activity: County Cumberland City or Township Hope Mills
3858 Gillespie Street 34.975955
Highway/Street_ Latltude(decimal degrees) Longitude(decimal degrees)
Approximate date land -disturbing activity will commence: 7/1 /2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 14.5
-78.911913
6. Amount of fee enclosed: $ 1,500 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Georgia Bell E-mail Address carol inacleaningandrestoration @ yahoo. corn
Phone: Office # 252-714-3936
Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Fayetteville Public Works Commission 910-433-1382
Name
PO Box 1089
Current Mailing Address
Fayetteville, NC 28302
City
10. Deed Book No. 10301
State
Phone: Office # Mobile #
955 Old Wilmington Road
Current Street Address
Fayetteville, NC 28301
Zip City
Page No. 0870
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Carolina Cleaning and Restoration, LLC
Company Name
105 Turner Run Drive
Current Mailing Address
Greenville, NC 27858
City State Zip
Phone: Office # 252-714-3936
[e-mail]
E-mail Address
105 Turner Run Drive
Current Street Address
Greenville, NC 27858
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Georgia Bell
Name of Registered Agent
105 Turner Run Drive
Current Mailing Address
Greenville, NC 27858
City
State
Phone: Office # 252-714-3936
Ryan Bell
[e-mail]
E-mail Address
105 Turner Run Drive
Current Street Address
Greenville, NC 27858
Zip City
Mobile #
Name of individual to Contact (if Registered Agent is a company)
State Zip
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
c acted informati should there be any change in the information prov'Ided herein.
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Signature Date
C1 Q 2 V-1 Lt a Notary Public of the County of
State of North Carolina, hereby certify that —1t a appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this J�day of �1' (C C 20
DELICIA J T KIMBRQUGN Notary r
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At Commission Expires 7-20-2022 Y expires