HomeMy WebLinkAbout01007_Food Lion_LURU Model_20170912NC BROWNFIELDS
LAND USE RESTRICTIONS (“LUR”) UPDATE
Year Certification Made: 2017
Name: Food Lion
Project #: 01007-97-034
Address: Waughtown & Sprague Streets
County: Forsyth
Property Owner (In part or whole):
Read the following LURs and mark each restriction accordingly. Additional remarks may be added for compliance status clarification. Attach any required or supplemental documentation,
sign, notarize and submit to the following address:
NC Division of Waste Management
Attn: Brownfields Program Staff
1646 Mail Service Center
Raleigh, NC 27699-1646
No water supply wells may be installed or used at the Brownfields Property.
☐ In compliance ☐ Out of compliance
Remarks: ______________________________________________________________
No mining activities may be conducted on the Brownfields Property.
☐ In compliance ☐ Out of compliance
Remarks: ______________________________________________________________
No activities which result in direct exposure to or removal of groundwater (for example, construction or excavation activities which encounter or expose groundwater) may be conducted
on the Brownfields Property without prior sampling and analysis of groundwater in the area where activities are to be conducted, provision of the analytical results to the Department
of Environmental Quality (“DEQ”) or its successor in function along with plans and procedures to protect public health and the environment during those activities, and approval of those
activities by DEQ.
☐ In compliance ☐ Out of compliance
Remarks: ______________________________________________________________
No fountains, ponds, lakes, or other items which are supplied, in whole or in part, by groundwater may be constructed on the Brownfields Property.
☐ In compliance ☐ Out of compliance
Remarks: ______________________________________________________________
A notarized Land Use Restriction Update must be submitted by the owner(s) of the Brownfields Property to DEQ on each biennial anniversary of the effective date (November 9th, 1999)
of the Brownfields Agreement certifying that the land use restrictions continue in force and are being complied with.
☐ In compliance ☐ Out of compliance
Remarks: ______________________________________________________________
Notarized signing and submittal of this Land Use Restrictions Update constitutes certification that the Notice of Brownfields Property remains recorded at the Forsyth County Register
of Deeds office and that the Land Use Restrictions are being complied with.
This Land Use Restrictions Update is certified by _____________, owner of at least part of the Brownfields Property on this ___ day of _________, 20__.
Name typed or printed of party making certification: __________________
[Note: additional entities or owners may be added if appropriate (i.e. multiple managing members/entities)]
By: __________________________ (signature)
Name typed or printed: __________________
Title typed or printed: ___________________
NORTH CAROLINA
__________ COUNTY
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the foregoing document for the purpose stated
therein and in the capacity indicated: ______________________.
Date: ____________ ___________________________________ Official Signature of Notary
____________________________________
Notary’s printed or typed name, Notary Public
(Official Seal) My commission expires: _________________