N1003 ROGER & MARIE WILSON

1�orkflow No. 628425
DRI�eonccVI1*MINIMUM
orded: D7/1322507004tTvoe: CRP
4/04
02:22:31 PM
Fes AM: $23.00 Page 1 of 4
workflow# 628425
Caldwell Countv. NC
wAVHE L RASH Realster of Deeds
aK1512 PD92&931
North Carolina
Department of Environment and Natural Resources
Division of Waste Management ✓DENR
Michael F. Easley, Governor William G. Ross Jr., Secretary qj/� N. matt s�p
William L. Meyer, Director Wo
i`�oores
LAND CLEARING AND INERT DEBRIS LANDFILL NOTIFICATION
Pursuant to 15A #CAC 13B .0563(2)(a), the land owners} and operators) of any Land Clearing and Inert
Debris Landfill under two (2) acres in size shall submit this notification form to the Division prior to
constructing or operating the landfill. This form must be filed for recordation in the Register of Deeds'
Office. The Register of Deeds shall index the notification under the name of the owner(s) of the land in
the county or counties in which the land is located. The Register's seal and the date, book, and page
number of recording must be included on this form when submitted to the Division. This notification is not
valid to authorize operation of a landfill unless complete, accurate, recorded, and submitted to the Division
as required by 15A NCAC 13B .0563(2)(b).
1 . Facility Name: c2 r /%/LiF Cii�SaiJ
2. Facility location (street address):._ 442o( 4& 9%or) Rc%
City: Lcwoa County: 'A&/",)A Lu Zip: •$A/09°4'
3. Directions to Site:_ 6WAW12 .L � %o A4451.rT.w w63T 14t ^0146�
c,� f1.y'siT
4. The land on which this landfill is located is described in the deed recorded in:
deed book: f.. page: county:
5. Name of land owner
6. Mailing address of la
City: L�/2 State: N•c• Zip: ,�.�(oS/5'
7. Telephone number of land owner:) :f2cQ I
If the land is owned by more than one person, attach additional sheets with the name, address,
and phone number of all additional land owners.
8. Name of operator: ICn�c2 /17/ai1fE Gy/ISsV
9. Trade or business name of operator:
10. Mailing address of
City: CL��r/L State: L'lr y Zip: ;>z b�lu �r
11. Telephone number of operator.( ,`'�� 1 ?� � ��/a
If
the landfill is operated by more than one person, attach additional sheets with the name,
address, and phone number of all additional operators. �
12. Projected use of land after completion of landfill operations: G.i}LU�ti —QryS • -
1646 Mail Service Center, Raleigh, North Carolina 27699-1646
Phone: [phone] \FAX: [phone] Internet: www.enrstate.nc.us/
AN EQ AL OPPORTUNITY \AFFIRMATIVE ACTION EMPLOYER- 50%RECYCLED / 1 D%POST CONSUMER PAPER
a3 °°

f51 120 calendar days ahar completion of any phase of disposal operations, or upon revocation of a permit, the disposal area shall be covered
with a minimum of one foot of suitable soil cover sloped to allow surface water runoff in a controlled manner. The Division may require further
action in order to correct any condition which is or may become injurious to the public health, or 3 nuisance to the community.
I6) Adequate erosion control measures, structures, or devices shall be utilized to prevent silt from leaving the site and to prevent excessive on
site erosion.
17) Provisions for a ground cover sufficient to restrain erosion must be accomplished within 30 working days or 120 calendar days upon
ompletion of any phase of landfill development.
(S) The facility shall be adequately secured by means of gates, chains, berms, fences, etc, TO prevent unauthorized access except when an
operator is on duty. An attendant shall be on duty at all times while the landfill is open for public use to assure compliance with operational
requirements and to prevent acceptance of unauthorized wastes.
f9) Access roads shall be of all-weather construction and properly maintained.
(101 Surface water shall be diverted from the working face and shall not be impounded over waste.
(111 Solid waste shall not be disposed of in water.
121 Open burning of solid waste is prohibited.
(131 The concentration of explosive gases generated by the facility shall not exceed:
(a) Twenty-five percent of the lower explosive limit for the gases in facility structures.
(b) The lower explosive limit for the gases at the property boundary. .
1141 Leachate shall be properly managed on site through the use of current best management practices.
151 Should the Division deem it necessary, ground water or surface water monitoring, or both, may be required as provided for under Rules .0601
and .0602 of this Subchapter.
(161 A sign shall be posted at the facility entrance showing the contact name and number in case of an emergency and the permit number. The
permit number requirement is not applicable for facilities not requiring an individual permit.
Certification by Land Owner:
I certify that the information provided by me in this notification is t� accurate, and complete to the vest
of my knowledge. The facility siting and disposal operations of s Land Clearing & Inert Debris landfill
will comply with the requirements of Sections .0563, .0564 and .0566 of 15A NCAC 13B, North Carolina
Solid Waste Management Rules. The facility and operations of this landfill will also comply with all
applicable Federal, State, and Local laws, rules, regulations, and ordinances. Where the operator is
different from the land owner, I, the land owner, have knowledge of the operator's plans to dispose of
solid waste on the land and I specifically grant permission for the operation of the landfill. I understand
that both the land owner and operator are jointly and severally liable for improper operations and proper
closure of the landfill as provided for by North Carolina General Statute 130A-309.27. I further understand
that North Carolina General Statute 13OA-22 provides for administrative penalties of up to five thousand
dollars ($5,000.00) per day per each violation of the Solid Waste Management Rules. I further understand
that the Solid Waste Management Rules may be revised or a nded in the future and that the.facility
siting and opera ns of this landfill will be required to com ifh alllsuc e isions or amendments.
Print Name (Owner) Signature (0w r) Date
North Carolina
�. o ( c� t,ie LL County
I, �VA`I me- L, be r fr�n , a Notary Public for said County and State, do hereby certify
that t'nuf,e J 94D%Af k.,d Son personally appeared before me this day and acknowledged the due
execution of the foregoing instrument.
;�til� ass my hand and official seal, this the �_ day of a�1j � 20�_.
�p, .,,...... Ce
• C T� ficj
_$dal)O�lh �- �td7uun
/.• ary Public �
:A 'nib
r•:V, 1
*ri rission expires 0 C 14 20 _.
K3

R30
Certification by Corporate Land Owner:
1 certify that the information provided by me in this notification is true, accurate, and complete to the best
of my knowledge. The facility siting and disposal operations of this Land Clearing & Inert Debris landfill
will comply with the requirements of Sections .0563, .0564 and .0566 of 15A NCAC 13B, North Carolina
Solid Waste Management Rules. The facility and operations of this landfill will also comply with all
applicable Federal, State, and Local laws, rules, regulations, and ordinances. Where the operator is
different from the corporate land owner, the corporate land owner, has knowledge of the operator's plans
to dispose of solid waste on the land and is specifically granted permission for the operation of the landfill.
It is understood that both the corporate land owner and operator are jointly and severally liable for
improper operations and proper closure of the landfill as provided for by North Carolina General Statute
130A-309,270 It is further understand that North Carolina General Statute 130A-22 provides for
administrative penalties of up to five thousand dollars ($5,000.00) per day per each violation of the Solid
Waste Management Rules. It is further understood that the Solid Waste Management Rules may be revised
or amended in the future and that the facility siting and operations of this landfill will be required to
comply with all such revisions or amendments.
Corporation Name f
(Corporate Seal)
President or Vice -President Name (Print)
President or Vice -President Signature
North Carolina
that
Attest:
Corporate Secretary Name (Print)
Corporate Secretary Signature
County
a Notary Public for said County and State, do hereby certify
(name of secretary) personally appeared before me this day and
acknowledged that he for she) is secretary of
(name of
corporation), a corporation, and that by authority duly given and as the act of the corporation, the forgoing
instrument was signed in its name by its
(president orvice-president),
sealed with
its corporate seal,
and
attested
by himself for
herself) as its secretary.
Witness my
an and official
seal,
this the
day
of 20_
(Official Seal)
Notary Public
My commission expires , 20
G�

North Carolina
Caldwell Cu�aU,y
THP� CERTIFICATE OF
n � � .v� n I �.n n ...--,
IS CERTIFIED TO BE�ORRECT.
Wayne L. Rash,
RE STER OF DE DS
BY:
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