NCC230117_FRO Submitted_20230113

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.
Project Name Kersey Valley MSW Landfill Areas 1-3�
2. Location of land -disturbing activity: County Guilford City or Township High Point
Highway/Street Kivett Drive Latitude(decima1 degrees) 35.9558 Long itude(decima[ degrees)-79.9254
3. Approximate date land -disturbing activity will commence: August 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): MSW Landfill
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 26.4
6. Amount of fee enclosed: $2,700 . 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 N Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name, Mike Spencer E-mail Address_ mike. spencer(dhighpointnc.gov
Phone: Office # 336-883-3433 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of High Point
Name
336-883-3215
Phone: Office #
P.O. Box 230 211 S. Hamilton Street
Current Mailing Address Current Street Address
336-918-9376
Mobile #
High Point
NC
27261
High Point
NC 27260
City
State
Zip
City
State Zip
10. Deed Book No.
See Attached
Page No.
See Attached
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).
City of High Point
Company Name
P.O. Box 230
Current Mailing Address
_ High Point INC 27261
City State Zip
robby.stone aPhighpointnc.gov
E-mail Address
211 S. Hamilton Street
Current Street Address
_High Point NC _ 27260_
City State Zip
Phone: Office # 336-883-3215 Mobile # [phone]
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:
Name of Registered Agent
NIA
Current Mailing Address
City
State Zip
NIA
E-mail Address
NIA
Current Street Address
C ity
Phone: Office # NIA Mobile # NIA
NIA
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
NIA
Current Mailing Address
E-mail Address
NIA
Current Street Address
NIA NIA
City State Zip City State Zip
Phone: Office # NIA Mobile # N/A
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.
Robby D. Stone P.E. Director of Public Services
Type or print name Title or Authority
71ye � �• 7- IZ-Z2_
Signature Date
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I, 6fa LO-oH +l /, Ve!�foe, f,/ , a Notary Public of the County of 'P-44 . 211
State of North Carolina, hereby certify that cM—z 0,. 5�-eA -eappeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
h
Witness my hand and notarial seal, this 4� r day of 11"&1 l y 20 Z
SHARON d�LIVLNGOOD
NOTARY PUBLIC
RANDOLPH COUNTY, NC
/::!;
'�X' -'d. Notary
My commission expires �Y