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HomeMy WebLinkAboutNCC220116_FRO Submitted_20220126FINANCIAL 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. Thermal Belt Outreach Ministry,Inc. 1. Project Name 2. Location of land -disturbing activity: County Polk City or Township Columbus Highway/Street Hope Valley Lane Latitude 35.25034 Longitude-82.20543 3. Approximate date land -disturbing activity will commence: upon approval 4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.65 Acres 6. Amount of fee enclosed: $130.00 . 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 'P 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name David Odom, P.E. E-mail Address davidodom@odomengineering.com Telephone 828-247-4495 Cell # 828-429-4355 Fax # N/A E Landowner(s) of Record (attach accompanied page to list additional owners): Thermal Belt Outreach Ministry, Inc. 828-894-2988 Name Telephone P.O. Box 834 134 White Drive Current Mailing Address Current Street Address Columbus NC 28722 City State Zip Columbus NC City State 828-894-0130 Fax Number 28722 Zip 10. Deed Book No. 369 Page No. 391 Provide a copy of the most current deed. Part B. and Deed Book No. 438 Page No. 1119 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. Thermal Belt Outreach Ministry, Inc. margot.carter@tboutreach.org Name E-mail Address Current Mailing Address Columbus NC city 134 White Drive Current Street Address 28722 Columbus NC 28722 State Zip City State ME Telephone 828-894-2988 Fax Number 828-894-0130 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 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: Margot B. Cater margot.carter@tboutreach.org Name of Registered Agent E-mail Address P.O. Box 834 134 White Drive Current Mailing Address Current Street Address Columbus NC 28722 Columbus NC 28722 City State Zip Telephone 828-894-2988 City State Zip Fax Number 828-894-0130 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. Margot B. Carter Executive Director Type or print name Title or 7th�ri]ty r Signature Date I, f, „rU,.,_ , a Notary Public of the County of 2o State of North Carolina, hereby certify that R.?!:: appeared personally before me this day and being duly orn acknowledged that the above form was executed by him. Witness and rtl 0hal seal, Notary Public : Polkc0linl_ MY CommE 2 07- P. O 27-202x3 CrA IR Cam\ this �-�day of 'Dtc_. , 20 3" 1 ota My commission expires _7