NCC231098_FRO Submitted_20230419

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 and/
or fax information unavailable, place NIA In the blank.)
Part A. Spring Branch Restoration Project
1. Project Name p g
2. Location of land -disturbing activity: County. Johnston CItr or Township Smithfield
Highway/street—Church St._ Latitude 35.506883 Longitude-78.344185
3. Approximate date land -disturbing activity will commence:
4/15/2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Restoration
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 1.06
6. Amount of fee enclosed: $ 200 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name Adam Spiller E-mail Address [e-mail]
Telephone [phone] cell # _ _ Fax #
9.
Landowners) of Record (attach accompanied page to list additional owners):
Town of Smithfield 919-934-2116
Name Telephone
P4 Box 761 350 E. Market St.
Current Mailing Address
Smithfield NC
Current Street Address
27577 Smithfield
City State Zip City
10. Deed Book No. see attached Page No.
Fax Number
NC _ 27577
State Zip
_ _ 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.)1f the company or firm is a sole proprietorship,
the name of the owner or manager may be 112fed as the financlaW responsible party.
KCI EnAmnmenial Techmftlaa and Constmofon Inc. [e-mail]
Name E-mail Address
4505 Falls of the Neuse Rd. #400
Current Mailing Address
Raleigh NC 27609
city state zip
Telephone [phone] _
same
Current Street Address
City State Zip
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:
NIA
Name E-mail Address
Current Mailing Address Current Street Address
City stabs
Telephone
Zip Clty
Fax Number_
State Zip
(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
CT Corporation [e-mail]
Name of Registered Agent E-mail Address
160 Mine Lake Court, Suite 200 same
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zlp City state Zip
Telephone[phone] 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 attomey-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.
Laurie Arensdorf
Type or print name
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Signature
o�EEonz No. �.a ear
Title or Authority
,-VA
Date
I, Tta ; 'Eniyot, 6W _ , a Notary Public of the County of
State of North Carolina, hereby certify that I-aAl-'�e-Aernzc) —appeared
personally before me this day and being duly swam acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this M% day of � � , 20
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12_06.2026 ?_
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