NCC223864_FRO Submitted_20221122

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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name Phase 5 & 6 - Uwharrie Regional MSW Landfill
2. Location of land -disturbing activity: County Montgomery City or Township N/A
S R 1137 35.33350-79.96390
Highway/Street Latltude(decimai degrees) Longitude(decimal degrees)
3. Approximate date land -disturbing activity will commence: July 18, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 60.87
6. Amount of fee enclosed: $ 6,100.00 . 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 Mike Gurley E-mail Address [e-mail]
Phone: Office # [phone] ext. 391 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Republic Services of North Carolina, LLC [phone] NIA
Name
18500 North Allied Way
Current Mailing Address
Phone: Office # Mobile #
18500 North Allied Way
Current Street Address
Phoenix AZ 85054 Phoenix
City
State
10. Deed Book No.417,407
Zip City
Page No. 524,833
AZ 85054
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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Republic Services of North Carolina, LLC
Company Name
18500 North Allied Way
Current Mailing Address
Phoenix AZ 85054
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
18500 North Allied Way
Current Street Address
Phoenix AZ 85054
City State Zip
Mobile # NIA
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:
CT Corporation System
Name of Registered Agent
160 Mine Lake Ct Ste 200
Current Mailing Address
Raleigh NC 27615-6417
City
State Zip
NIA
E-mail Address
160 Mine Lake Ct Ste 200
Current Street Address
Raleigh NC 27615-6417
City State Zip
Phone: office # [phone] Mobile # NIA
NIA
Name of Individual to Contact (if Registered Agent is a company)
(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:
CT Corporation System NIA
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200 160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615-6417 Raleigh NC 27615-6417
City State Zip City State Zip
Phone: office # [phone]
NIA
Mobile # NIA
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.
NIA
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
corrected information should there be any change in the information provided herein.
William Maness
Type or p nt name
Signature
General Manager
Title or Authority
Date
I, "O, Tu I/ . hi -Son S , a Notary Public of the County of 4% '3/t00/her}
State of North Carolina, hereby certify that bi f O-m P 17gaAcSS 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 17 " day of , 200��
(�V'44=14
9t�
�6fary
My commission expires

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Montgomery County
910-576-4221 NIA
Name
Phone: Office # Mobile #
102 East Springs Street
102 East Springs Street
Current Mailing Address
Current Street Address
Troy NC
27371
Troy NC 27371
City State
Zip
City State Zip
Deed Book No. 394,408
Page No. 311,424 Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City
Deed Book No._
Landowner 5 of Record:
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
Current Mailing Address Current Street Address
City State Zip City
Deed Book No. Page No.
Mobile #
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 5 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #