NCC240848_FRO Submitted_20240326

NC Dept of Environmental Quality
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT JUL 11 Mf::
No person may initiate any land-disturbing activity on one or more acres as covered b the Act before this form
and an acceptable erosion and sedimentation control plan have been completed a�f � tbt� �
Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, placft/A in the blank.)
Part A.
1. Project Name: Franklin County Solid Waste Convenience Center
2. Location of land-disturbing activity: County: Franklin County City or Township: Younasville
Highway/Street: Long Mill Road Latitude: 36002'34.90" N Longitude: 78030'08.71" W
3. Approximate date land-disturbing activity will commence: April 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Solid Waste
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.2 acres
6. Amount of fee enclosed: 1195.00. The application fee of$65.00 per acre(rounded up to the next acre)
is assessed without a ceiling amount(Example: a 9-acre application fee is$585).
7. Has an erosion and sediment control plan been filed? ❑Yes❑ No® Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: Michael S. Schriver E-mail Address: [e-mail]
Telephone#: [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Franklin County, A North Carolina body politic 919-496-5994 N/A
Name Telephone Fax Number
113 Market Street 113 Market Street
Current Mailing Address Current Street Address
Louisburg_ North Carolina 27549 Louisburg North Carolina 27549
City State Zip City State Zip
10. Deed Book No. 2316 Page No.1425-1427 A copy of the most current deed is provided.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Franklin County N/A
Name E-mail Address
113 Market Street 113 Market Street
Current Mailing Address Current Street Address
Louisburg North Carolina 27549 Louisburg North Carolina 27549
City State Zip City State Zip
Telephone: [phone] Fax Number: N/A

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:
NIA _
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number-
(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:
NIA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
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.
Kimberly B. Denton County Manager
Typ or rint na a Title or Authority
Boa 3
Signature Date
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a Notary Public of the County of n��,
State of North Carolina, hereby certify that Kimberly B. Denton 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 �u dayof C��YI� , 20_�
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