NCC242834_FRO Submitted_20241002

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name: 1-74 Industrial Center Sewer Improvements
2. Location of land-disturbing activity: County: Randolph City or Township: Randleman
Highway/Street: Commonwealth Rd, Hunters Ridge Rd, Academy St., Tigers Den Rd., Holder St.,
Brookshire Rd., N Stout St.. Poplar St., Randolph St.
Latitude: 35°49'43.27" N Longitude: 79°50'21.47"W(location of sewer pump station)
3. Approximate date land-disturbing activity will commence: Fall 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):12.496 Acres >13 Acres
6. Amount of fee enclosed:$845. The Express Permitting application fee is a dual charge. The normal fee
of$65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the
Express Permitting supplement is$250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is$2,585).
7. Has an erosion and sediment control plan been filed? Yes Enclosed X
8_ Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name:John C. Grey E-mail Address:[e-mail]
Telephone: [phone] Ext. 102
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Randleman [phone] [phone]
Name Telephone Fax Number
204 S Main Street 204 S Main Street
Current Mailing Address Current Street Address
Randleman NC 27317 Randleman NC 27313
City State Zip City State Zip
10. Deed Book No. Page No._ Provide a copy of the most current deed_
Part B.
1. 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.
Randolph County [e-mail]
Name E-mail Address
725 McDowell Rd. 725 McDowell Rd
Current Mailing Address Current Street Address
Asheboro NC 27205 Asheboro NC 27205
City State Zip City State Zip

Telephone [phone] Fax Number
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:
NA
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:
NA
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) 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.
Type or print na : Hal Johnso Title or Authority: County Manager
6 - (7 - a3
Signature Date
I, i�t r fr-PeJ( ( .(t , a Notary Public of the County of Ir1 G r o/Jloh
State of North Carolina, hereby certify that HA t c\akn36 vA appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
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Witness m fi '!I•.1. -' t- opal, this • day of cal thl�. , 20 a 3
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