NCC230486_FRO Submitted_20230224

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.)
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Project Name Grove Park Stream Restoration Project
Location of land -disturbing activity: County Durham City or Township Oak Grove
Highway/Street Nichols Farm Drive, Holder Road, and Northlake Drive
Latitude (decimal degrees) 35.970808' Longitude (decimal degrees)-78.823136'
Approximate date land -disturbing activity will commence: Summer 2022
Purpose of development (residential, commercial, industrial, institutional, etc.):
Water quality and habitat improvement proiect through stream restoration.
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 17 ac
Amount of fee enclosed: $1,700. 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.
Has an erosion and sediment control plan been filed? Yes xI Enclosed El No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kayne Van Steil E-mail Address kayne(a)waterlandsolutions.com
Phone: Office # 919-614-5111 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
Grove Park Community Association, Inc.
Name
300 Nichols Farm Drive
Current Mailing Address
Durham, NC 27703
City State Zip
Deed Book No. 2438 Page No. 235
Deed Book No. 6185 Page No. 750
Provide a copy of the most current deed(s).
919-957-7672 919-957-7704
Phone: Office # Fax #
Same
Current Street Address
Same
City State Zip

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).
Durham Soil & Water Conservation District
Company Name
201 E Main Street, 5th Floor
Current Mailing Address
Durham, NC 27701
City State Zip
Phone: Office # 919-560-0558
eculberson(o-)_dconc.gov
E-mail Address
Same
Current Street Address
Same
City State Zip
Fax # [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:
N/A
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip
(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:
N/A
Name of Registered Agent
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
Eddie Culberson
Type or print name
s
Signature
District Director
Title or Authority
Aaeo-
Date
ia e1 a Notary Public of the County of
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 fL F day of fc-`} 20
+. 4W �.►,. Notary
3 My commission expires
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