NCC240659_FRO Submitted_20240306

Che k if this project is ARPA-funded 0
Attach a cop of the Letter of Intent to Fund
FINANCIAL RESPONSIBILITY/OWNERS IP FORM
SEDIMENTATION POLLUTION CONTR L ACT
No person may initiate any land-disturbing activity on one or more acres s covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, before this form
and an acceptable erosion and sedimentation control plan have been c mpleted 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 Deep Run Volunteer Fire Dept Hwy 258 Site
*If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure(DWI).
2. Location of land-disturbing activity: County Lenoir City or Township Woodington
Hwy258 South 35.1190 -77.6420
Highway/Street LatltUde(decimal degrees) LOngltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 2/1/24
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4.3
6. Amount of fee enclosed: $500 . The applicati n fee of$100.00 per acre (rounded
up to the next acre)is assessed without a ceiling amount (Exampl : 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Encl sed El No ❑
8. Person to contact should erosion and sediment control issues arise uring land-disturbing activity:
Name Chris Smith E-mail AddressS [e-mail]
Phone: Office# 252-521-6182 Mobile#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Deep Run Volunteer Fire Dept 252-521-618
Name Phone: Office# Mobile#
PO Box 71
Current Mailing Address Current Street Add ess
Deep Run NC 28525
City State Zip City State Zip
10. Deed Book No. 1977 Page No. 1 12 Provi e 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).
Deep Run Volunteer Fire Dept
Company Name E-mail Address
PO Box 71
Current Mailing Address Current Street Adcress
Deep Run NC 28525
City State Zip City State Zip
Phone: Office#252-521-6182 Mobile#
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 regist red on the NC Secretary of State
business registry,give name and street address of the Registered A ent:
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)
(b) If the Financially Responsible Party is not a resident of North Car lina, give name and street address
of the designated North Carolina agent who is registered on the NC ecretary 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 com an y)

(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 Respo sible Party is an individual, General
Partnership,or other company not registered and doing business und-r 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 knowl-dge 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 Respontible Party). I agree to provide
corrected information should there be any change in the informatio provided herein.
Christopher Smith President
Type or print name Title or Authority
Cjinet444/../
/24/-2-C
Signature Date
I Kendall Taylor , a Notary Public of the County of Lenoir
State of North Carolina, hereby certify that Christopher Smith appeared personally
before me this day and being duly sworn acknowledged that the abo e form was executed by him/her.
Witness my hand and notarial seal, this I I day of , 20
it
aO •a,0 Not-ry
(Mb 0'c AR My commission e, pires 11/28/2028
2

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 Ad ress
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 Addr-ss
City State Zip City State Zip
Deed Book No. Page No. Provi.e a copy of the most current deed.

Continued from Item 1 in Part B of the Financial Responsibility/0 ership Form for multiple parties.
Attach copies of this page as needed to list all financially responsi•le 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 Add~ess
City State Zip City State Zip
Phone: Office# Mobile#