NCC216686_FRO Submitted_20220105

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 NIA in the blank.)
Part A. South Eldridge Road Water Main Extension
1. Project Name 9
2. Location of land -disturbing activity: County Sampson City or Township Newton Grove
Highway/Street SR-1644 Latitude See attachment Longitude See attachment
I Approximate date land -disturbing activity will commence: October 202
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Water Utility Improvements
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 Linwood Reynolds, PE E-mail Address [e-mail]
Telephone [phone] Cell # 910.385.4418 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NIA NIA NIA
Name Telephone Fax Number
NIA NIA
Current Mailing Address Current Street Address
NIA NIA
City State Zip City State Zip
10. Deed Book No. N/A Page No. N/A 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.
Sampson County c/o Linwood Reynolds [e-mail]
Name E-mail Address
827 Southeast Blvd. 827 Southeast Blvd.
Current Mailing Address Current Street Address
Clinton, NC 28328 Clinton, NC 28328
City State Zip City State Zip
Telephone [phone] Fax Number 919.592.7242

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:
NIA
NIA
Name
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State Zip
City State Zip
Telephone N/A
Fax Number N/A
(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:
NIA
NIA
Name of Registered Agent
E-mail Address
NIA
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State Zip
City State Zip
Telephone N/A Fax Number N/A
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.
Linwood Reynolds
Type or print name
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Signature
Public Works Director
Title or Authority
9 ZFPZZI
Dates .,._... .
I, 1-CQ�1LlY1U SY1GtYltilA� 1 _ a Notary Public of the County of, MVSEJ3 1,
State of North Carolina, hereby certify that LANV Tod &` J WO-16k 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 JL�tday of SQ,1'?4"GI VW , 202-1
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