NCC223823_FRO Submitted_20221115

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity that disturbs one or more acres as covered by the Town of
Clayton Soil Erosion and Sedimentation Control Ordinance before this form and an acceptable erosion and
sedimentation control plan have been completed and approved by the Town of Clayton. Lots smaller than one
acre that are part of a larger plan of development are also subject to Town of Clayton Soil Erosion and
Sedimentation Control Ordinance and are required to complete this form. (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.
1. Project Name Johnston Health Medical Office Building
2. Location of land -disturbing activity: County JOHNSTON City or Township CLAYTON
Highway/Street NC Hwy. 42W Latitude 35.63279 Longitude -78.49802
3. Approximate date land -disturbing activity will commence: September 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Medical Office
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.7 acres
6. Has an erosion and sediment control plan been filed? Yes ✓ No Enclosed
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kyle McDermott E-mail Address [e-mail]
Telephone [phone] cell # 919-398-8082 Fax # q lq - b 5— 066 ✓
8. Landowner(s) of Record (attach accompanied page to list additional owners):
Johnston Memorial Hospital Authority 919-585-8000 Gi
Name Telephone Fax Number
P.O. Box 1376 2138 NC Highway 42 W.
Current Mailing Address Current Street Address
Smithfield NC 27577 Clayton NC 27520
City State Zip City State Zip
9. Deed Book No. 03557 Page No. 0788 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.
Johnston Memorial Hospital Authority
Name
2138 NC Highway 42 W.
Current Mailing Address
Clayton NC 27520
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
2138 NC Highway 42 W.
Current Street Address
Clayton NC 27520
City j State Zip
Zip
c
Fax Number 9 1 �. ^5 9 - Sou

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:
N/A
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:
NA
Name of Registered Agent
Current Mailing Address
aty
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.
Uo�e %-es. S� 6 r _.�rv% ceJ
Title or Authority
,?--la - 26,ZZ
Date
1, S. M Q I �1 a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being duly swo n acknowledged that the above form was executed
by him.
Witness my hand and notarial seal,
Notary Public s
r?�� County
MY Com`t�r W n Ex 1 S=
Tiq C P, Ok
this day of Vl _, 202-ZI
Notary
My commission expires �v�