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rtteb "" NORTH CAROLINA DEPARTMENT OF
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081WIM 12:01 1414 ENVIRONMENT AND NATURAL REsoURCE,S
errrett K. aiRl WD?
byiwt. r of P0.411 ArY]S10N OF WwsTE MANAGEMCtyT
LAND CLEARING AND INERT DEBRIS LANDFILL NOTIFICATION
Pursuant to 15A I�CAC t 3E .0563(2)(a), the land owner(s) and operator(sl of any Land
Clearing and inert Debris Landfill under two (2) acres in site 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 heeds' 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 seat 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 138 .D563121(bl.
1, Facility Name: + C L. CV Cen+
2. Facility location (street address)Jr 2C2 5HEC p )� t; S _ For-O , P-Q • ��
City: 50-L i - G:, aniy: ,,,, F+,v Zip:'U 1111
3. Directions to Site: Kwyr (5a
4. The land on which this landfill is located is described in the deed recorded in:
Deed Book: Page:_ _L z _ County:�eW.a�.�
5. ✓dame of land owner: kltJ • _ u.PL C Y _ _
6. Mailing address of land owner: V7 0 51)r e e "j �5 Poe o
City: �Jfi '- State:
7. Telephone number of land owner.-( `)oY 1 4r33 - (r
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.
a. Name of operator: L), 1
8. Trade or business name of operator: F e £
10. Mailing address of operator:1,715 f 'gf-" Its 17;jeo 8d_-- -
City: _`lg-t_r s ayey State:. Q . Zip:-2219:2
1 i. Telephone number of operator:(_-)Q y ) is 33 - v,4 3 --_---
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:
k t YJ 4-
of Poor Quality Due to Condfllan of
Document - G.S. 101 - 14
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Page 2 of 4
The following are the applir;ability, siting, and operating Criteria for Land Clearing and Inert Debris Landfills
operating under notification.
.0101 DEFTNMONS
172f '!arid elesring waste' meant solid waste which It generated solely Irom land clearing azimiirs such as stumps, Chaos, limbs, brush, press, and
other neturalty occurring vsgetall- mslenei.
(731 'Land clearing and Inert debris jandfjh' maent a facility for the land disposal of land ettaring waste, concrete, brick. Conertno labek,
Uncontarninetcd soil, gravel end rock, untreated and vnpdnled wood. and yard trash.
1741 'Ysrd trash' mt.ns sotid wane resutlina lrom landscaping and yard mwnirnence much as brush. grass. time limbs. end slmdsr vegetative
mamrimfa.
.0663 APPLICABILITY MOUIREMENTS FOR LAND CLEAMNO AND }NEAT DEBRIS 1LC1D) LANDFILLS
Management of land clearing +rid inert debris shall be in accordance wish the State hierarchy for managing ■oho want me provided for under N.C.G.5, I
130A•308.0410. Disposal in a landfill is considered to be The least desirable method of managing land clearing mind inert debrim. Where tonal (iftg is
necessary. the requirements of this Fluid apply.
(11 An Individual permit tram the Division of Solid Wastc Managements not requirad for Land Clearing and Inert Dabris (LVDI )mndFals thin ?met
all of the following candhions:
1n) The Iscifity is to be operated for Vol disposal of land eleonng waste. Inert debris, unimeted wood, and yard trash. operations must
be corn; nem sad in compliance with the local government acrid waste management plan as approved by the O}visivn of Sold Waste
Management.
lb) The total disposal miss is under two ezms in size.
fr) The ls6lity and practi_es comply wash the siting criteria under Rule .0564. end opere6onal nogw;mrrrenta under Rule .0666.
tell The fell activity is not exempt Imm. and must comply with oil other Federal. State. or Local Iowa, ordinonems, Rules, regulstiorr, or
orders, inchdiry but rod bridled to zoning retInCtiorr, flood plain restnctionc. wetland reRrclions. sedimentation wW erosion Conoof
requhemertta, and mining roguletions.
12) Where an Individual permit is not rogvired, the following ■ppliea:
161 Tire owrwraf the )and miens the landfrg is located must notify the Division on a prescribed lortn, duty signed, merited, and recorded
as per Rule .OS6312ilol• The operator of the landfill. if dillsrent from the land owner, shall also sign line newieetien Ivmt.
(b) The owner must isle the prescribed nulificd6on form for rocordation in the Register of Deeds' Ot ice. The Rogalor at Dw6a shoh index
the notification in the grantor index under the name of the owner or the tend in the county or counties in which the land Is located.
A copy of the recorded notification. affixed with the Register's sad and the date. boot and peps number of recording shag be ment
to the Oivicion of Solid Watte Management.
(cf 1Yhcn Vre lend an which the Lend Cien,ing and Inert Debris Landfill is said. leased, conveyed, or transforred In rrrymanrrr, the dead
or other instrument of transfer shell conl6h In the descriytian seciiar, in ao mmaller type then that used In the body of the dead or
'rewurnent a staumer.: that the pruperty )ea: been usad as a Land Clearing and Inan Debris Landfill and a mforenee by beck and page
to the recordalion of the natilleation.
.061?A SITING CRITERIA FOR LAND CLEARING AND INERT DEBRIS rLCIDI LANDFILLS
The folrowrrrg milling crtlene shall apply for Land Clearing and Inert Debris lLC1Dl landfills.
11) Facif les or practices. shalt nut be located in the 164yoor floadpWn.
121 Facilities or practices stealj not cause or contribute to the taking of any endangered or threatened species of plorns. fish. or wildlife.
l3} Forlinie■ or practices shelf not itsuh in the dortruchon or adverse modification et the critics? habilst of endangered or thremmMd opeeM as
identified in 60 CFR Part 17 which is hereby incorporated by rolerenea Including any subsegveni amendmontt and 846oras. This malarial is
■voilabre for inspection or stir Department of Environment. Health. end Natural Resources. Division of Solid Wane Monsgement, 401 obrdirl
Rood, Raleigh. North Carolina 771305 wnere copies can be obtained at no coal.
141 Focilnias or practices shall not damage of destroy an archaeological or historical one.
5) Feclillos or prawces ahjX not cause An edwise impact on a stole park. recreation or actinic s»a, or any other lands Included In the Crate nature
and historic promerve.
(6) Facilt ies shall not be located in any weltard as defined in the Clean Water Act, SeClWn 4041bl.
(71 It mast be ■)1Zn n Ihal adequalc Suitable wile art ■vail&blG for cover, either from on or oti site.
18) Land Cle mring and Inert Debris landfills shag me ct the touowing surfer and ground water requiromerats
to) Fmckbm or practices slydf not cause a discharge of pollulanta into watan of tux st4to that Is in violation of the requirerMrne of the
Nslional Poliulanl Discharge Eiiminetion System CHFIMS), under Section 402 of the Clean Water Act, so arrendad.
(b1 Factlnies or practices shall not caws a discharge of dredged materiels or fill material into waters of the etste that -is in violation of
the requirements under Section 404 o1 the Gam Wolof Act, as amended.
Ic) Faciltiea or prmctcaa shall not smug non -point source pollution of warem of the state that vieletes aseign id water 4usfny etendaMe.
(4) Wine in I"fius with a disposal area greater than two acres she)) be placed is minimum 91 lour loot above ter seasonal ligh wetw
table, except whom an ahrmdive separation is approved by the Division.
Is) Waste in londfrl4 with A deposal wam leas than two acres shall be placed above the seasonal high wash table.
10) The facility shall moot the following minimum buffer requirementc:
(d 60 toot from the wmslo boundary to all surface wavers of Me stets ae dahnsd In 0.9, 141212.
lb} 100 loot lram the diapusal vivo to piuperty lines. residential dwellings, commercial or public buildings. end wells,
10 Buller requirements may be adjusted as necessary fa insure adequate protoc6on of public health and the environment.
001 The f►cil ry shall Most aH hequjrernenls of Any applicable toning ordinance.
.0665 OPERATIONAL REQUIREMT_NTs FOR LAND CLEARwO AND INERT DEBRIS ILC1Dj LANDFILLS
Land Clearing and Inert Debris ILCID) landlilis shall meat the following operational requirements
11) Oparetionat plans shall be approved and followed as specified for the facility.
(2) The fact ay oholl only accept those solid wastes whicrr it is prrntled W necaivm.
(31 Solid woetr shag be restricted to the an+allect Area feasible and compacted as densely, as piectical hina wire.
(4) Adequate soil cover sha11 be applied monthly, or when dra attire area reaches one acre in airs, whichever ocrumv Pest.
(61 120 calendar drys attar cempir ion of any phase of dispersal operations, or upon rowtstion of a pwmil, the deposal arms shol be cove ed with
■ nirir urn of are foot of auitablo vA cover sloped to allow surface water rlrnoH at a centroliad manner. The Divistim ray requite hathw action
in order to correct any condition which is or may bscorhe injurieum to this pubfiic health, or a isuimaneo to the emmmaatlty.
WI Admgatmm arosix+ cortoal measures. abuctwre. w devices shag be 6614h d to prevent sill tmm leaving the this wild to prevent us+mmehs on gip
nation.
(71 Provisos fa a ground saves va06ent to rmsti sin erosion must W mcedmplished within 410 wroAdro days or 120 dalmrdw dates upon wstrpledon
of any phase of londGh dovelopmens.
0) The facility "be adequmtak amolaW by mew of gates. chain. berm, lances. etc, m prevent weutharbod &comes &aRslpt w haR Las oPwator
e M duty. An atanldrn shY be on duty at all times whr'nv the iond(W i open For public ursa to ,mauve eortioamom weft cipwrodo ter regtrh.rrrnrs
and to prevent acceptance of wauthoriled wastes.
19) Access roads %hall be of mWwasther sonrtrvcYon and property maintetred.
Record of Poor Ouellty Due to Condition of Y
Original Document - G.S. 101 - 14
Page 3 of
i 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. I have
informed the land owner of my plans to dispose of solid waste on the land and the land owner has
specifically granted permission for the operation of the landfill. I understand that troth the operator and
land owner 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. 1 further understand that North Carolina
General Statute 130A-22 provides for administrative penalties of up to five thousand dollars
1$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 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.
w A 1 )z 8 I _al aq
Print Name (Oper oil Signature faperata Date
00 Lz' A"�) I -. County
/ N a �'/ _ _, a Notary Public for said County and State, do hereby certify that
personally appeared before me this day and acknowledged the due
execution of the foregoing instrument.
�I C7)l R*ts my hand and official seal, this the _ /►'�� _ day oll 19_Q_L_�.
r �'•p tr�Rc�s�i�iaf-•Seal]
,��� '' '.,•'. •;•'I Notary Publa
My commission expires J
For additimllat land owners and landfill operators, attach separate notarized certifications for each
owner and landfill operator.
For Corporate land owners andfor operators, use the Corporate Certifications, pages 5 and 6
of Solid Waste Management for proper applicable certifications.
Notification or Land C+ swig and Baer[ Debris Land Iil„ „rider two (21 acres in s'.ze is required under 16 NrAC 138 .0563(2j(@I. Comact Ow saw
Wane Section at the address below for further inlunr�etian.
Division of Waste hisnagarnent
Solid Waste Section
Po Box 29603
Ratvigh, North Carolina 27611.9603
I91p) 733.0692
DisposxLcin; This form wrR ba tranatergd to Lta irate Autv,da Canter when hlarenee value ends. Records will be hold lot sp ricy In ON Blate
Racorda Gi7zer fire (6) additional yeah end then iranalorred to the custody el the Atahires.
Record of Poor Quatity Due to Condition of
Original Document - G.S. 101 - 14
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• I101 Surfoee water shell be diverted from the Working face and shall Ml be imppunded oval went.
I111 Solid wade shell not be diapossd of in water,
1121 Opon bun709 of ivEd waste is prohibited,
1)X The CCneentratif)n of eXPlosive Dallas generated by lhs iscilny shell not exceed:
gel Twsnty-fiva percent of the Sower e�qiIyci,a limit for the pa.es in recilay ttruchsrec.
(b) The 10 War exphaive &mir rw the pasta al the pmporty boundary.
it'll Gschsm shell be properly managed on silo thmugh the ust of current beat management pra:lices.
r161 Should tht Division 4eem It necossary, ground .rater or aurtsce water monitoring, or both, rosy be required as ptavided for under Aules JWJ
and .0602 of thrc Subchapter.
116I A sign sha➢ tit polled at tFe faz3ry mmrw:e aho'nrtg V* cnntsut nano and number In case of on amerpenty and the permit number. The permit
number raquirement is not appkable for lecilgma not requiring an Individual parlph.
Certification by Land Owner:
I 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 ,OS66 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 frorn the land owner, 1, 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. 1 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. I further understand 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..
Print Name (0w ri 1 Signature (Owner) Date
North Carolina
A a,, }} County
Ir ►r K 4?lQtPq a Notary Public for said County and State, do hereby certify that
X AI f Li • personally appeared before me this day and acknowledged the due
execution of the foregoing instrument.
Witness my hand and official seal, this the Aly day of V S4 19 ,
(Official Seal)
Notary P tic f 6
My i;ommission expires_ �0� t-6 6 8_ 1,�•.
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NORTH CAROLINA: ROWAN C NTY O 1 �f 3
(�� The foregoing certiriicateaof..... ...t. .... N.P. of....f:.Sfifilil/ /.. ..'./.� ..............
as�erUfied to be correct. �( q
Fired for registration this .......... ........... .A..........day of.......................�+`t..........................................19 q.f............
�b M. E'r a Re,&Jr. of Detds
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