NCC215223_FRO Submitted_20210917

FINANCIAL 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. Cher Lane SanitarySewer Outfall
1. Project Name_ Cherry
2.
3.
4.
5.
Location of land -disturbing activity: County Alamance City or Township Graham
Highway/Street Cherry Lane Latitude 36.055628 LonyitUdP -79.353622
Approximate date land -disturbing activity will commence: 04/01 /2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.75
6. Amount of fee enclosed: $ 2,205 . 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 Aaron Holland E-mail Address [e-mail]
Telephone [phone] cell # NSA Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Graham [phone]
Name
P.O. Drawer 357
[phone]
Telephone Fax Number
201 South Main Street
Current Mailing Address Current Street Address
Graham NC 27253 Graham NC 27253
City State Zip City State Zip
(Easements obtained by City and provided as separate attachment)
10. Deed Book No. _ _ _ Page No,_ 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 orfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
City of Graham [e-mail]
Name
P.O. Drawer 357
Current Mailing Address
Graham NC
City
E-mail Address
201 South Main Street
Current Street Address
27253 Graham
State Zip City
NC 27253
State Zip
Telephone [phone] Fax Number [phone]

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:
N/A
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City State Zip
Telephone 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:
N/A
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Telephone 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:
Alley, Williams, Carmen, & King, Inc. [e-mail]
Engineering Firm or other consultant
Troy King, P.E.
Individual contact person (type or print)
E-mail Address
[phone]
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 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.
Aaron Holland
Type or print name,
&OIA, /Wac�
Signature
Assistant City Manager
Title or Authority
Date
I, �-- • J a Notary Public of the County of. Ai►4%4 91,OC-E
State of North Carolina, hereby certify that ArkV_eAJ appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal, this Z day of 20_Z�_L
.ON_MW.MO_W 6L�4z
DARG�6a�. SPERRY
Notary Public, North Carolina My commission expires
Alamance County
My Commission Expires
February03, 2025