NCC222568_FRO Submitted_20220810

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT DEQ f=/sYE�VIf�f�(�tC��iUl:� No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
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form and an acceptable erosion and sedimentation control plan have been completed and approved b
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 a
or fax information unavailable, place N/A in the blank.) -mail and/
Part A. Sludge
1. Project NameRemoval Plan for Existing Sludge Storage Site Anson Co.
2. Location of land -disturbing activity: County Anson
City or Township Lilesville
Highway/Street Clark Mountain Road 34.968872
Latitude Longitude-79•936785
3. Approximate date land -disturbing activity will commence: June 2020
4. Purpose of development (residential, commercial, industrial, institutional etc.: Sludge Removal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.5
6. Amount of fee enclosed: $ 1,040.00
fee up to the next acre) is assessed without a ceiling amo nte(Exxalmple: ication a 9-acre appli attiion acre (roun
fee is $585 ed
7. Has an erosion and sediment control plan been filed? Yes X )
__ No_______ Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mike Sessions
E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Clark Mountain LLC
Name
PO BOX 796 Telephone Fax Number
Current Mailing Address 1605 Cedar Grove Church Road
Polkton, NC 28135 Current Street Address
city Polkton, NC 28135
State Zip City
state
10. Deed Book No. 1170 p
Part B. 0116
Zi
Page No. Provide a copy of the most current deed.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity Provide
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.
Anson County - Barron S. Monroe II [e-mail]
Name
101 S. Greene Street E-mail Address
Current Mailing Address
Wadesboro, NC 28170 Current Street Address
City State
Zip City State
Telephone [phone] Zip
Fax Number

(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 Current Street Address
City State Zip City
State Zip
Telephone 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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State
Zip
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 hpm-in
Barron S. Monroe II
Typ r print name
,Agnature
County Manager
Title or Authority
=az� (� 2 &j ,9.6-
Date
a Notary Public of the County of '6
State of North Carolina, hereby certify that 13 f't-D Vj S. / I o�
executed by him. �-�� ��
personally before me this day and being duly sworn acknowledged that the above fopmeared was
Witness my hand and notarial seal, this jLday of 4 20 2,Q
PM. A�'�2�'%
•OVAR), • 'Seal
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ONrCOV� �.
otary
My commission expires DiQd a