NCC215720_FRO Submitted_20211019

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: City of Whiteville — Phase 2 — Sewer Improvements
2. Location of land -disturbing activity: County: Columbus City or Township: Whiteville
Highway/Street: Main St., Lee St. Frazier St., Caldis St. Lat: 34°19'11" N Long: 78042'16" W
3. Approximate date land -disturbing activity will commence: May 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal/Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.9 Acres
6. Amount of fee enclosed: $195.00. 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: Darren Currie, Manager E-mail Address: [e-mail] Ile. nc.us
Telephone: [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT and the Ci of Whiteville
Name Telephone Fax Number
Current Mailing Address Current Street Address
City
10. Deed Book No.
State
Zip City
Page No.
State
Zip
Provide a copy of the most current deed
Part B.
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):
Name
City of Whiteville, NC
Current Mailina Address
P.O. Box 607
Whiteville, NC 28472
E-mail Address
[e-mail]
Current Street Address
317 South Madison Street
Whiteville, NC 28472
Telephone: [phone] Fax Number: 910-642-6004

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 E-mail Address
Current Mailing Address
City State Zip
Telephone
Current Street Address
City
Fax Number
State Zip
(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 State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
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.
Darren Currie
ype r print name
Signature
Manager, City of Whiteville, NC
Title or Autho ity
9&�;
7
Date
I, _Bonn" ,1e 1 j V �J J+ l I I �''rLS a Notary Public of the County of
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State of North Carolina, hereby certify that 0-t'4'Yr) ('-f� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness my hand and notarial seal, this day ofS. VY�C�-K , 20 c9 i
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Notary
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