NCC216399_FRO Submitted_20211123

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 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. Shadowlawn Aerial Sewer Crossing Replacement
1. Project Name g p
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Shadowlawn Drive Latitude 35.073 Longitude-78.909'
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): municipal sewer
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.32 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 Nisha Thuruthy E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
see attached
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No, see attached 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 companyorfirm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Fayetteville PWC, c/o Misty Manning misty. [e-mail]
Name
955 Old Wilmington Road
Current Mailing Address
Fayetteville NC 28301
City State
Telephone [phone] ,-4V
E-mail Address
same as mailing address
Current Street Address
same as mailing address
Zip City
_ Fax Number
State
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:
NOT APPLICABLE
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:
NOT APPLICABLE
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.
K l5' �'_)OnnOo_
Type or rint name
Signat e r
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L�'l! A4 ! t AC,{I Cc V
Title or . -Authority
Date I
, a Notary Public of the County of
C,)mblev1cIrld
State of North Carolina, hereby certify that M` S�'LA He? Y)nI n_9 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 1'J day of Oct b-e,- 20 �1- 1
ELIZABETH T VASSER
Notary Public Notary
eal Cumberland County
North Carolina My commission expires ) v h'e of a ,