NCC230806_FRO Submitted_20230323

NL' VQV
MAR 10 20f FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
al Office
pmlei 0&6may initiate any land -disturbing activity on one or more acres as covered by the Act before this foram
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 Lake Michie Raw Water Pump Station Improvements
2. Location of land -disturbing activity: County Durham City or Township Bahamas
7019 Lake Michie Dam Road 36.1500-78.8300
Highway/Street Latitudeia�ma� ea��a�s} Longitudetae��me� d��s:�
3. Approximate date land -disturbing activity will commence: 03/20/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.98
6. Amount of fee enclosed: $ 0 . 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 fled? Yes p Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tyler Bexley E-mail Address [e-mail]
Phone: Office # 864-661-1740 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Durham 919-560-4381 919-749-5510
Name
Lori Montgomery
Current Mailing Address
Durham, NC 27701
City State
10. Deed Book No. 000129
Phone: Office # Mobile #
101 City Hall Plaza
Current Street Address
same
Zip City
Page No. 000556
State
Zip
Provide a copy of the most current deed.

NC Dept of Environmental Quality
Part B.
Com an res who are financially res onsiRR le fo p y(' ) y p bL)and-disturbing activity (Provide a comprehensive list
of all responsible parties on acc anied age.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of theVrfinancially responsible party(ies).
Crowder Industrial Construction LLC [e-mail]
Company Name
1990 New Cut Road
Current Mailing Address
Spartanburg, SC 29303
City
State Zip
Phone: Office # 864-661-1701
E-mail Address
1990 New Cut Road
Current Street Address
Spartanburg, SC 29303
City State Zip
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:
Lynn L. Hansen
Name of Registered Agent
6425 Brookshire Blvd
Current Mailing Address
Charlotte, NC 28216
City State Zip
Phone: Office # 704-716-5144
[e-mail]
E-mail Address
6425 Brookshire Blvd
Current Street Address
Charlotte, NC 28216
City
Mobile # [phone]
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
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

e t
NC D P of EnvitionmenO Qua""
MAR }cit L Financially Responsible Party is engaging in business under an assumed name, give name under
Which ft"Ieeany is Doing Business As. If the Financially Responsible Party is an individual, General
Raleigh RR44Mhip, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
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.
Dion Dreher
Type or pri
Signature
Vice President
Title or Authority
Date
I, Laura A. Childers , a Notary Public of the County of Spartanburg
State of North Carolina, hereby certify that Dion Dreher 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 ?#\- day of `-/IrL4 r-4 , 20?,?
.' ... zi'l /2 A L z
Notary-- - -
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