NCC240272_FRO Submitted_20240131

I rel 188?
Town of
Public Works Department
I 140 Memorial Park Court Southern Pines,NC 28387
Telephone: [phone] Fax:[phone]
Clouthern Ines
The Micln15oiil Resot FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
Internationally RecomIzed for Prognttn Excellence SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity greater than 30,000 sq.ft. as covered by the
Town's Code of Ordinances before this form and an acceptable erosion and sedimentation control
plan have been completed and approved by the Town of Southern Pines and the Land Quality Section,
NC. Department of Environmental Quality. (Please type or print and, if the question is not applicable
or Information unavailable, place N/A in the blank.)
Part A.
Food Bank
1. Protect Name
2. Location of land-disturbing activity: Highway/Street/Address: 195 Sandy Avenue,Southern Pines,NC,28387
Latitude 35.27361 Longitude 79.69833 County Moore City: Southern Pines
3. Approximate date land-disturbing activity wilicommence July 15, 2022
4. Percent impervious
5. Purpose of development(residential,commercial, industrial,institutional,etc.): Commercial
6. Total acreage disturbed or uncovered(including off-site borrow and waste areas):1
7. Amount of fee enclosed: $ 300
The application fee of$300.00 per acre plus $150.00 for each additional acre, or part thereof, and is
assessed without a ceiling amount. Any substantial revision to a previously approved,active plan is$50
per acre,or part thereof.
8. Has an erosion and sediment control plan been filed? Yes No Enclosed X
9. Person to contact should erosion and sediment control Issues arise during land-disturbing activity:
Name Peter Werbicki E-mail Address [e-mail]
Telephone [phone] Cell 919-875-0707 Fax
10. Landowner(s)of Record (attach accompanied page to list additional owners):
Food Bank of Central&Eastern North Carolina 910-692-5959
Name Telephone Fax Number
1924 Capital Boulevard Same
Current Mailing Address Current Street Address
Raleigh, NC, 27604 Same
City State Zip City State Zip
11. Deed Book No.5520 Page No, 496 Provide a copy of the most current deed.
Page 3 of 3 1-6-21 B-81

Part B.
1. Person(s),Company(ies),or firm(s)who are financially responsible for the land-disturbing activity(Provide a
comprehensive list of all responsible parties on an attached sheet.)if the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Food Bank of Central & Eastern North Carolina [e-mail]
Name E-mail Address
1924 Capital Boulevard, 1924 Capital Boulevard
Current Mailing Address Current Street Address
Raleigh, NC, 27604 Raleigh, NC, 27604
City State Zip City State Zip
Telephone [phone] Fax
2. (a) If the Financially Responsible Party is not a resident of North Carolina,give name and street address of the
designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed
name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation,
give name and street address of the Registered Agent:
Peter Werbicki pwerbicki(c�foodbankcenc.org
Name of Registered Agent E-mail Address
1924 Capital Boulevard same
Current Mailing Address Current Street Address
Raleigh NC 27604 same
City State Zip City State Zip
Telephone [phone] Fax Number
Page 3 of 3 1-6-21 B-82

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 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 Person). I agree to provide corrected information should there be any change in the
information provided herein.
Peter Webicki President/CEO
Type or print name Title or Authority
'abook 7 (1,1 2-e/Z,
Signature Date
I, 14141V // , a Notary Public of the County of /r61V1 V I i
State of North Carolina, hereby certify that ter t hi f -.i' appeared
personally before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this I Z day of J 16U�)Y//��1t' , 20 2 2
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Seal IV't, ' UB L1G
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My commission expires !V '� (,
FOR TOWN USE ONLY:
Covered by 5/70 Provision: Yes ❑ No ❑
REVISED:December 17,2020
Page 3 of 3 1-6-21 B-83