NCC223007_FRO Submitted_20220830

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. Fair Bluff Uptown Business Center
1. Project Name p
2. Location of land -disturbing activity: County Columbus City or Township Fair Bluff
Highway/Street Main St Latitude 34.314218N Longitude 79.034191 W
3. Approximate date land -disturbing activity will commences Jan 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.). Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5
6. Amount of fee enclosed: 195 . 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 Al Leonard E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Fair Bluff 910-649-7426 910-649-7151
Name
PO Box 157
Current Mailing Address
Fair Bluff NC 28439
Telephone Fax Number
1054 Main St
Current Street Address
Fair Bluff NC 28439
City State Zip City State Zip
10. Deed Book No. 1247, 1247, Page No. 106-107, 108-110 Provide a copy of the most current deed.
Part B. 1249, 1249 76-78, 259-260
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.
Town of Fair Bluff [e-mail]
Name E-mail Address
PO Box 157 1054 Main St
Current Mailing Address
Fair Bluff NC 28439
City State
Telephone [phone]
Zip
Current Street Address
Fair Bluff NC 28439
City State Zip
Fax Number 910-649-7151

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
Tele
State
E-mail Address
Current Street Address
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.
Billy Hammond
Type or print name
Signat
Mayor
Title or Au/thhority j
l_ /CO - 'r� I
Date
1, M , a Notary Public of the County of
State of North Carolina, hereby certify that Ri Ilu 44mmoMappeared
personally before me this day and being duly s acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Aday of , 20A I
Q�' T A Notary
N °Seal-
G7: �* My commission expires da�v
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