NCC215616_FRO Submitted_20211011

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Environment and Natural Resources. (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 Albemarle Food Bank
2. Location of land -disturbing activity: County Pasquotank City or Township Elizabeth City
Highway/Street Tidewater Way Latitude 36016'11.5"N Longitude 76°12'30.6"W
3. Approximate date land -disturbing activity will commence: August 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.65
6. Amount of fee enclosed: $ 130.00 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
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 Sean Robey E-mail Address [e-mail]
Telephone [phone] Cell # 252-339-1745 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Food Bank of the Albemarle 252-335-4035 x110
Name
P.O. Box 1704
Current Mailing Address
Elizabeth City NC 27906
City State Zip
Telephone
109 Tidewater Way
Current Street Address
Elizabeth City NC
City State
252-335-4797
Fax Number
27906
Zip
10. Deed Book No. 685 Page No. 375 Provide a copy of the most current deed.
Part B. addl: D.B. 973, PG. 494
D.B. 627, PG. 324
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Food Bank of the Albemarle Ireasoner afoodbank.or
Name E-mail Address
P.O. Box 1704
Current Mailing Address
Elizabeth City
City
109 Tidewater Wa
Current Street Address
NC 27906 Elizabeth City NC 27906
State Zip City State Zip
Telephone [phone] x110 Fax Number 252-335-4797

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
E-mail Address
Current Street Address
State Zip 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:
Liz Reasoner
Name of Registered Agent
PO Box 1704
Current Mailing Address
Ieasoner afoodbank.or.
E-mail Address
109 Tidewater Wa
Current Street Address
Elizabeth City NC 27906 Elizabeth Ci
City State Zip City
Telephone [phone] x110
Fax Number 252-335-4797
NC 27906
State Zip
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.
Liz Reasoner
Executive Director
T p r rint name Title or Authority
T2 Lzl
Si nature Date
[, S , a Notary Public of the County of
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
Lt Z tie-r— appeared
duly sworn acknowledged that the above form was
Witness my hand and notarial seal, thisca-<g?!I�day of '3 uA W 20 ate_
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