HomeMy WebLinkAboutNCC215233_FRO Submitted_20210917FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION 08012007
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 N/A in the blank.)
Part A.
1. Project Name Nine Mile Storage
2. Location of land -disturbing activity: County Carteret City or Township Newport
Highway/Street Nine Mlle Road Latitude 34.728 Longitude-76.939
3. Approximate date land -disturbing activity will commence: September 10, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.45
6. Amount of fee enclosed: $ 1 890 . The Express Permitting application fee is a dual charge.
The normal fee of $65.00 per acre is assessed without a ceiling amount. In addition, the Express
Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting
supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). NOTE: Both fees are
rounded up to the next whole acre and need to be paid by separate checks to NCDENR.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name David Bradley E-mail Address dbradley@ec.rr.com
Telephone 252-240-9799 Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nine Mile South Holdings, LLC 252-240-9799
Name Telephone Fax Number
118 Buena Vista Dr. 118 Buena Vista Dr.
Current Mailing Address Current Street Address
Newport NC 28570 Newport NC 28570
City State Zip City State Zip
10. Deed Book No. 1 627 Page No. 339 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.) if the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Nine Mile South Holdings, LLC dbradley@ec.rr.com
Name E-mail Address
118 Buena Vista Dr. 118 Buena Vista Dr.
Current Mailing Address Current Street Address
Newport NC 28570 Newport NC 28570
City State Zip City State Zip
Telephone252-240-9799 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:
Name
Current Mailing Address
City
Telephone
State
Zip
E-mail Address
Current Street Address
City State Zip
Fax Number
(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:
Name of Registered Agent
Current Mailing Address
City
Telephone,
State
Zip
E-mail Address
Current Street Address
City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
The Cullipher Group chase@tcgpa.com
Engineering Firm or other consultant E-mail Address
Charles Cullipher 252-773-0090
Individual contact person (type or print) Telephone 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 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 Person). I agree to provide corrected information should there be
any change in the information provided herein.
David Bradley
Type o_�,Kint
Signature
Manager
Title or Authority
8/25/2021
Date
I, 1 n t Ayen R . Fps ce U X _._,a Notary Public of the County of CaAtyck
State of North Carolina, hereby certify that -.uM id appeared personally
before me this day and being duly sworn acknowledged that the above forth was executed by him.
Witness my hand and notarial seal, this 2�J day of P\u 20'Z�_
`0%IM111/ j,%? ��� �fleaQa�iotary
po My commission expires 11 Ow 2O% y
PUBLIC
il�ftloqo%O I
*Z:
xllk
OIN