NCC216323_FRO Submitted_20211118

FINANCF , RESPONSIBILITY/OWNERSHIP FORM
SEDIM—ATATION POLLUTION CONTROL AC
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.
Project Name Erosion and Sedimentation Control Plan Maury Volunteer Fire and Rescue
2. Location of land -disturbing activity: County Greene City or Township Farmville
Highway/Street US-258 S Latitude 35.520 Longitude-77.613
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Fire Station
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.23
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 Joseph W. McKemev E-mail Address iwm2 mcdavid-inc.com
Telephone [phone] Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Maury Volunteer Fire and Rescue Association, Inc.
Name
P.O. Box 217
Current Mailing Address
Maury NC 28554
City State Zip
[phone]
Telephone
3659 Hwy 903 N
Current Street Address
Snow Hill NC
City
State
[phone]
Fax Number
28580
Zip
10, Deed Book No. 731 Page No. 471 Provide a copy of the most current deed.
Part B.
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.
Maury Volunteer Fire and Rescue Association, Inc.
Name
P.O. Box 217
Current Mailing Address
Maury NC 28554
City State Zip
[e-mail]
E-mail Address
3659 Hwy 903 N
Current Street Address
Snow Hill NC
City
State
Telephone [phone] Fax Number [phone]
28580
Zip

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 State
Telephone
E-mail Address
Current Street Address
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:
Fred Wade
Name of Registered Agent
101 Clarence Moye Rd.
Current Mailing Address
Ayden, NC 28513
City State Zip
Telephone [phone]
[e-mail]
E-mail Address
101 Clarence Move Rd.
Current Street Address
Ayden, NC 28513
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.
Neil E. Jarman
Type or print name
Signature
------------
Chief, Maury Volunteer Fire and Rescue
Title or Authority
Date Q19124
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a Notary Public of the County of
GrGt��
State of North Carolina, hereby certify that INe;t F. c rlkc-� &— appeared
personally before me this day and being duly swom acknowledged that the above form was executed
by him.
Witness my h,%M(�pj g?tAo,11 seal, this
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Notary 0'
My commission expires �0 �Z��