NCC230944_FRO Submitted_20230404

NC Dept of Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT BAR 7 2023
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 a r '
Quality Section, N.C. Department of Environmental Quality. Submit the complete or o appro
Regional Office. (Please type or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Little River Raw Water Pump Station Improvements
2. Location of land-disturbing activity: County Durham City or Township Durham
Highway/Street 6225 Snow Hill Drive Latitude(decimal degrees)36.1090 Longitude(decimal degrees)-78.8730
3. Approximate date land-disturbing activity will commence:6/20/2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.1
6. Amount of fee enclosed: $ -. 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 EJ 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 Phone: Office # Mobile#
Lori Montgomery 101 City Hall Plaza
Current Mailing Address Current Street Address
Durham, NC 27701 same
City State Zip City State Zip
10. Deed Book No.0001 29 Page No.000556 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).
Crowder Industrial Construction LLC [e-mail]
Company Name E-mail Address
1990 New Cut Road 1990 New Cut Road
Current Mailing Address Current Street Address
Spartanburg, SC 29303 Spartanburg, SC 29303
City State Zip City State Zip
Phone: Office# 864-661-1701 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 [e-mail]
Name of Registered Agent E-mail Address
6425 Brookshire Blvd 6425 Brookshire Blvd
Current Mailing Address Current Street Address
Charlotte, NC 28216 Charlotte, NC 28216
City State Zip City State Zip
Phone: Office# 704-716-5144 Mobile# [phone]
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
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.
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 Vice President
Type or print name Title or Authority
©3/o61zo1j
ig ature Date
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 4 �� day �!�of a , 20 oUAlAii a II. e-,W.4 {_46-
Notary
My commission expires /O/7/3<
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