NCC216089_FRO Submitted_20211108

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Environmental Quality. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Project Blue Sky Infrastructure
2. Location of land -disturbing activity: County Stanly City or Township 0akboro
Highway/Street See plans Latitude See plans Longitude See plans
3. Approximate date land -disturbing activity will commence: March 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): utilltieS
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.81
6. Amount of fee enclosed: $ 455 , 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 Doug Burgess E-mail [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Oakboro 7044853351
Name Telephone Fax Number
109 N Main St, #A 109 N Main St, #A
Current Mailing Address Current Street Address
Oakboro NC 28129 Oakboro NC 28129
City State Zip City State Zip
10. Deed Book No. See plans Page No. see plans 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.
Doug Burgess [e-mail]
Name E-mail Address
109 N Main St, #A 109 N Main St, #A
Current Mailing Address Current Street Address
Oakboro NC 28129 Oakboro NC 28129
City State Zip City State Zip
Telephone [phone] 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 E-mail Address
Current Mailing Address Current Street Address
City 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
Doug Burgess
Type or print nap
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Signature
Town Administrator
Title or Authority
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Date
%t.{�. `�` I, CWld2c.{ a Notary Public of the County of s
State of North Carolina, hereby certify that O tru p, (-�U_FAG5S appeared
personally before me this day and being duly s n acknovAdged that the above form was
executed by him.
Witness my hand and notarial seal, this __[3day of 20_._24 _—
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Notary
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