NCC220200_FRO Submitted_20220111

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.
Project Name Rocky Fork Asphalt Plant
2. Location of land -disturbing activity. County Lee City or Township Sanford
Highway/Street_130 Rocky Fork Church Rd Latitude 35023'54.48"N Longitude-79013'38.72"W
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.60
6. Amount of fee enclosed: $ 585 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 Richard Oldham E-mail Address roldham(8 anfordcontractors.com
Telephone [phone] Cell # _919-356-5483 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Donald T. Oldham _919-842-0274 N/A
Name Telephone Fax Number
PO Box 149 N/A
Current Mailing Address Current Street Address
Lemon Springs N.C. 28355 N/A
City State Zip City State Zip
10. Deed Book No. 01240 Page No. 0317 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.
Donald T. Oldham [e-mail]
Name E-mail Address
PO Box 149 N/A
Current Mailing Address Current Street Address
Lemon Springs N.C. 28355 N/A
City State Zip City State Zip

Te l e p h o n e_919-842-0 36 8
Fax Number N/A
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
Telephone
E-mail Address
Current Street Address
State 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State 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.
l')bnald Oify-I
ype print
Signature
I, ?_� oli-b Arc_
puOn ert_
Title or Authority
No✓ 29 ZOZI
Date
el I . a Notary Public of the County of
Le- -e_
State of North Carolina, hereby certify that Do^a l J -7. 0I0\ V1cLr-" appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
A�.4.�t ojgt �� rl
Vllitness m � � tarial seal, this
Notary public _
too Counly -
Seal
Y CIARI���„��.
day of N"C"6cr 20ZI
\�:s o_a &,,-
Notary
My commission expires l%- 1-202,2-