NCC220181_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 Environment and Natural Resources. (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 Martin County Landfill - Borrow Area -1
2. Location of land -disturbing activity: County Martin City or Township Williamston
Highway/Street Landfill Road Latitude 35.8633 Longitude-77.0960
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Landfill Operations
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.9 Acres
6. Amount of fee enclosed: $ 390 . 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 Justin Harrison E-mail [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
_Martin_ County [phone] 252 789-4309
Name Telephone Fax Number
305 E. Main Street
Current Mailing Address Current Street Address
Williamston NC 27892
City State Zip City State Zip
10. Deed Book/Page Nos.. DB A-13/Pages 441-442; DB T-15/Pgoes 712-713• DB V-26/Pa es 898-899:
DB Y-11/Pa es 662-663 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Martin Count manage rmartincount nc ov.cc)m
Name E-mail Address
305 E. Main Street
Current Mailing Address
Williamston NC_ 27892
City State Zip
Telephone [phone]
Current Street Address
City State Zip
Fax Number (2521 789-4309

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 Zip
Telephone
E-mail Address
Current Street Address
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 State
Telephone
E-mail Address
Current Street Address
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 by any change in the information provided herein.
U. James Bennett
Typ -or-print ame
Signature
County Manager
Title or Authority
/o//Z121
Date
EIX a Notary Public of the County of
State of North Carolina, hereby certify that2rappeared 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 I day of OG-�Dtory , 20
JULIA S REASE .�
NOTARY PUBLIC CL
MARTIN COUNTY, NC Notary
My commi ion xpires 7- 7-2026
My commission expires 7 'X.,6