NCC233327_FRO Submitted_20231129

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 N/A in the blank.)
Part A.
1. Project Name Statesville Utility Yard
2. Location of land-disturbing activity: County Iredell City or Township Statesville
Highway/Street 915 Winston Ave. Latitude(decimal degrees) 35.7710 Longitude(decimal degrees) -80.8940
3. Approximate date land-disturbing activity will commence: November 13, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 11.9 Acres
6. Amount of fee enclosed: $ 1,200.00 . 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 ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Ryan Fonville E-mail Address [e-mail]
Phone: Office# [phone] Mobile# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Statesville [phone] [phone]
Name Phone: Office# Mobile#
PO Box 1111 915 Winston Ave.
Current Mailing Address Current Street Address
Statesville NC, 28687 Statesville NC, 28677
City State Zip City State Zip
10. Deed Book No. 3017 Page No. 2298 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 names)of the owner(s)may be listed as the financially responsible party(ies).
City of Statesville [e-mail]
Company Name E-mail Address
PO Box 1111 227 S. Center St.
Current Mailing Address Current Street Address
Statesville, NC 28687 Statesville, NC 28677
City State Zip City State Zip
Phone: Office# [phone] 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:
-711/1-.6.1-7- r5' i- S it tz WI 1 Ie.r)c .0 t
Name of Registered Agent E-mail Address
17ioxh ( 7-?...1 s . ,e , /, st,
Current Mailing Address Current Street Address
fbct,I C ,'.1- 2 11 ,t14L5/ (It X16 zIs(071
City State Zip City State Zip
Phone: Office# 1 oif f ci- D - s i (( Mobile# 7 D 7 9 Y b ' i0 o 7)
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.
441\1
T e or print nam Title or Aut�onty�
gfr4,44 0/3/ /25
Slg'iature
Date
1, Q - , a Notary Public of the County of '2-ft,A4,11
State of North Carolina, hereby certify that "� 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 0211 day of NovR.,,,,,, Y , 2013
lAterk
Notary
Seal
My commission expires o3—d` a,J
Brenda Fugett
5 Notary Rom
Veda County
North Carolina - 35 ti
M Commission Ex•lras+, __ '�,�.3

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:
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 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 State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 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.

Continued from Item I 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#

ROY COOPER t3;r� _ !1
Governor ,ti
ELIZABETHS.BISER k� 'J j1r� �.
Secretary
DOUGLAS R.ANSEL NORTH CAROLINA
Interim Director Envtror+mentalQuality
July 21,2023
LETTER OF APPROVAL WITH MODIFICATIONS
City of Statesville
Attention: Ron Smith, City Manager
301 South Center Street
Statesville,North Carolina 28677
RE: Project Name: Statesville Utility Yard
Project ID: IREDE-2023-018
Acres Approved: 11.9
County: Iredell
City: Statesville
Location: Winston Ave/SR134
River Basin: Yadkin-PeeDee
Stream Classification: Other
Submitted By: WithersRavenel
Date Received by LQS:July 7,2023
Plan Type: Revised
Dear Mr. Smith:
This office has reviewed the subject erosion and sedimentation control plan. We find the plan to be
acceptable with modifications and hereby issue this letter of Approval with Modifications.The
Modifications Required for Approval are listed on the attached page.This plan approval shall expire three
(3)years following the date of approval, if no land-disturbing activity has been undertaken,as is required
by Title 15A NCAC 4B .0129.
As of April 1,2019,all new construction activities are required to complete and submit an electronic
Notice of Intent(eNOI)form requesting a Certificate of Coverage(COC)under the NCG010000
Construction General Permit. After the form is reviewed and found to be complete,you will receive a link
with payment instructions for the$100 annual permit fee. After the fee is processed,you will receive the
COC via email. As the Financially Responsible Party shown on the FRO form submitted for this
project,you MUST obtain the COC prior to commencement of any land disturbing
activity. The eNOI form may be accessed at deq.nc.gov/NCG01. Please direct questions about
the eNOI form to the Storrnwater Program staff in the Raleigh central office. If the owner/operator of this
project changes in the future,the new responsible party must obtain anew COC.
Title 15A NCAC 4B .0118(a)and the NCGO 1 permit require that the following documentation be kept on
file at the job site:
Noah Carolina Department of Environmental Quality I Division of Energy,Mineral,and Land Resources
n= ftft1)"k92)
Mooresville Regional off ice 1610 East Center Avenue,Suite 3011 Mooresville,North Carolina ZS 115
M-6634699

•
Letter of Approval with Modifications
City of Statesville
July 21,2023
Page 2 of 3
1. The approved E&SC plan as well as any approved deviation.
2. The NCG01 permit and the COC,once it is received.
3. Records of inspections made during the previous 30 days.
Also,this letter gives the notice required by G.S. 113A-61.1(a)of our right of periodic inspection to
ensure compliance with the approved plan.
North Carolina's Sedimentation Pollution Control Act is performance-oriented,requiring protection of
existing natural resources and adjoining properties.If,following the commencement of this project,it is
determined that the erosion and sedimentation control plan is inadequate to meet the requirements of the
Sedimentation Pollution Control Act of 1973 (North Carolina General Statute 113A-5 1 through 66),this
office may require revisions to the plan and implementation of the revisions to ensure compliance with the
Act.
Acceptance and approval of this plan is conditioned upon your compliance with Federal and State water
quality laws,regulations,and rules. In addition,local city or county ordinances or rules may also apply to
this land-disturbing activity.This approval does not supersede any other permit or approval.
Please note that this approval is based in part on the accuracy of the information provided in the Financial
Responsibility Form,which you provided.You are requested to file an amended form if there is any
change in the information included on the form.In addition,it would be helpful if you notify this office of
the proposed starting date for this project.
Your cooperation is appreciated.
Sincerely,
/)0/mAfr. eA
Jerry W.Eplin,PE
Assistant Regional Engineer •
Land Quality Section
JWE
Enclosure: Certificate of Approval
Modifications Required for Approval
NCG01 Fact Sheet
c: WithersRavenel
Attention: Chuck Boecker,PE
424 Gallimore Dairy Road, Suite C
Greensboro,North Carolina 27409
�� r'/� North Carolina Department of Environmental Quality i Division of Energy,Mineral.and Land Resources
Mooresville Regional Office 1610 East Center Avenue,Suite 3011 Mooresville,North Carolina 28115
arnl 704.663-1699

Letter of Approval with Modifications
City of Statesville
July 21,2023
Page 3 of 3
MODIFICATIONS REQUIRED FOR APPROVAL
Project Name: Statesville Utility Yard
Project ID: IREDE-2023-018
County: Iredell
Reviewed by: Jerry W. Eplin,PE
1. A 20-foot-wide limit of disturbance (LOD)is shown around the southern and eastern portion of the
site. Based upon conversations with the Engineer,the referenced disturbance is for cutting trees
while leaving the roots,and, for fence installation,with no disturbance to the stream that the LOD
crosses. Modify Sheets C6.00 and C6.01 to indicate that there will be no disturbance to the streams,
and that only tree cutting while leaving the roots, and fence installation with no impact to stream and
no grading. Also indicate that if equipment must cross the stream at any point,timber mats must be
utilized.
2. All temporary diversions installed in Phase I must remain as long as possible in Phase II. Temporary
diversion 1 must remain, maintaining positive drainage to the basin,until the storm drain system on each
side of the diversion is operational. Due to the critical nature of this part of the construction sequence,
the pre-construction meeting with the DEQ•DEMLR erosion and sediment control inspector should be
considered mandatory.
3. Provide outlet protection for the discharge location of the proposed storm drain along Winston Avenue.
4. The emergency spillway for Basin#3 should not be at the same elevation as the top of berm. The
emergency spillway should be at least one foot below the top of berm, as per the North Carolina Erosion
and Sediment Control Planning and Design Manual. Additionally,the riser elevation shown on Sheet
C8.00 does not match the riser elevation shown in the SCM profile view. Please correct this drawing.
5. Provide two updated full-sized sets of drawings to this office within 2 weeks,or prior to starting land
disturbance,whichever is sooner.
6. Additional measures may be required-The applicant is responsible for the control of sediment on-site. If
the approved erosion and sedimentation control measures prove insufficient,the applicant must take
those additional steps necessary to stop sediment from leaving this site. [15A NCAC 4B .0115]
Ref: G.S. 113A-54.1 through G.S. 113A-57
Sections 15A NCAC 04A.0101 through 15A NCAC 04E.0504
General Permit NCG 010000 NPDES for Construction Activities
North Carolina Department of Environmental Quality I Division of Energy,Mineral,and Land Resources
Mooresville Regional Office 1610 East Center Avenue,Suite 301 I Mooresville,North Carolina 281 1 5
704 663.1699

Fact Sheet on the New NCGO1 Permit _EQ
April 2019 -�
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Organizational Updates Acronyms to Know
The new permit: COC: Certificate of Coverage,proof of coverage under an NCG01 permit
• Repeats state requirements for E&SC DEMLR: NC Division of Energy,Mineral,and Land Resources
Plans and organizes them with federal E&SC: Erosion&Sedimentation Control
construction activity requirements; e-NOI: Notice of Intent,application form for the NCGO1 permit
• Is clearly organized by topic;and e-NOT: Notice of Termination,form for closing out the NCG01 permit
• Has less text and more tables. SWPPP: Stormwater Pollution Prevention Plan,required by the NCG01
Technical Updates
The new permit:
• Requires that the E&SC Plan meet
SWPPP requirements(p.2);
• Provides a list of items that must be
included in the SWPPP,such as the
construction sequence,plans,
calculations,etc.(p.2-4);1
• Has updated language on bypasses and
upsets that is tailored to construction
activities(p.10);
• Puts all timeframes for inspections,
record-keeping and reporting in The NCGO1 Process
"calendar days"for clarity and The new NCGO1 applies to permits approved on or after April 1,2019.
consistency(p,11-14);2 Permittees will no longer receive a copy of the NCG01 permit in the mail
• Changes the inspection frequency with their E&SC Plan approvals and be considered as covered under the
(during business hours)to at least
once per 7 calendar days and after permit.Federal rules require that DEMLR receive an NOI on each
every storm>1.0 inch(previously 0.5
construction project and issue each construction project its own COC.
inch);3 and Under the new NCGO1 process,construction sites will continue to
• Excludes weekends,state and federal receive approval for E&SC Plans from either DEMLR or the delegated
holidays from normal business hours local E&SC program just like before.After receiving E&SC Plan approval,
unless construction activities take permittees will officially obtain coverage under the NCGO1 by
place(p.23). completing an e-NOI(available at dea.nc.eov/NCG01). The e-NOI will
only take about 20 minutes to fill out and submit on-line.
1 This list is based on website guidance Initially,there will be no charge associated with applying for an NCG01
by the DEMLR Sediment Program.
2 The number of calendar days was permit but on or around June 1,2019,DEMLR will begin charging a$100
selected to be as equivalent as annual general permit fee as required per§143-215.3D.
possible with the previous permit. DEMLR is working on creating a single application form that will allow an
3 The intent is to provide predictability applicant to simultaneously apply for an E&SC permit and an NCG01
to the inspection schedule. COC.That effort is part of a larger Permit Transformation project at
DEMLR.

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Why do construction sites have to do this extra application step? How does the new NCGO1 affect the
DEMLR is required by the EPA to issue a specific COC to every construction delegated local E&SC Programs?
site that disturbs one acre or more. DEMLR is working to create a form Local programs will continue to review
that combines the E&SC plan approval and e-NOI processes,but that will and approve E&SC plans.However,
take more time.For now,DEMLR has created an efficient e-NOI process. they will no longer send copies of the
NCGO1 with E&SC Plan approvals.
If an E&SC Plan is approved before April 1,which permit applies? DEMLR will provide sample language to
Projects with already approved E&SC Plans will automatically follow the use in local E&SC Plan approvals to
new NCGO1 permit,but will not need to fill out an e-NOI or pay an annual advise permittees that they must
permit fee.However,the permittees should print the new permit and the submit an e-NOI to DEMLR.
two standard detail sheets and have them on site.
Will DEMLR offer tools to help permittees comply with the new NCGO1?
Yes,DEMLR will provide two sample plan sheets at deo.nc.gov/NCGO1 that
can be placed into the E&SC plan set.The first covers the site stabilization
and materials handling portions of the permit. The second sheet covers
the inspection,record-keeping and reporting portions of the permit.
How will the new e-NOI submittal and COC process work?
Permittees will apply for E&SC Plan approvals from DEMLR or the local
E&SC program like before.The E&SC approval letter will instruct the
permittee to visit dea.nc.gov/NCGO1 to submit an e-NOI form to DEMLR. Local programs are not required to
The permittee may begin the construction activity after receipt of the COC check if permittees have submitted e-
(within three days*).The permittee must print and retain a copy of the NOls to DEMLR.However,if they wish
permit and the COC on site.Initially,the COC will be issued for free but on to do this voluntarily,there will be a
or around June 1,2019,a$100 annual general permit fee will be charged. tool available on DEMLR's web site for
them to view a list of construction
Who is allowed to submit an e-NOI form? projects that have submitted e-NOls.
Submittal must be by a responsible corporate officer that owns or
operates the activity,such as a president,secretary,treasurer,or vice When local programs close out an E&SC
president or a manager that is authorized in accordance with IV.B.6 of the Plan,the close-out letter will advise
NCGO1 permit. Additional signatory options are set forth in IV.B.6 of the permittees that they must submit an e-
permit. It is possible for consultant to prepare the e-NOI,save it as a draft, NOT. DEMLR will provide sample
and email it to the responsible entity for signature&submittal. language.
What happens to the COC when the construction activity is complete? Local programs may approve E&SC
When a project is complete,the permittees will contact DEMLR or the local plans that meet state sediment laws
delegated program to close out the E&SC Plan.After DEMLR or the local and rules even if those plans are not
E&SC program inform the permittee of the project close out via inspection compliant with all of the NCGO1
requirements.However,their
report,the permittee will visit deo.nc.eovINCG01 to submit an e-NOT. permittees will be required to add two
Will there be a grace period for adherence to the new process? plan sheets(which will be provided by
DEMLR does not have the authority to grant a grace period from a DEMLR)to their E&SC Plans to ensure
federally mandated permit.Permittees will be informed of the new that they fully comply with the ground
process via web site,E&SC Plan approval letters and list servs. If a stabilization, materials handling,and
construction activity disturbs one acre or more(or is part of common plan inspection,record-keeping and
of development that disturbs one acre or more)fails to submit an.e-NOI reporting portion of the NCGO1 permit.
after approval of its E&SC Plan,this is a violation of federal permitting *
requirements and the permittee could be subject to a penalty assessment. Or 24 business hours for a project
approved under the DEMLR Express
review program.

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