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HomeMy WebLinkAboutNCC220589_FRO Submitted_20220207FINANCIAL 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. 1. Project Name Owen Park Subdivision, Phase 1 2. Location of land -disturbing activity: County Alamance City or Township Gibsonville Highway/Street Aspen Ave. Latitude 36.090184 Longitude -79.532475 3. Approximate date land -disturbing activity will commence: October 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 39.3 6. Amount of fee enclosed: $ 2,600 . 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 Matt Kirkpatrick E-mail Address mattk@reliant-partners.com Telephone Cell # (919) 235-8304 Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Owen Park Associates, LLC (919) 235-8304 Name Telephone Fax Number 4004 Barrett Dr., STE. 204 4004 Barrett Dr., STE. 204 Current Mailing Address Current Street Address Raleigh, NC 27609 Raleigh, NC 27609 City 10. Deed Book No. Part B. State 3956 Zip City Page No. 0173 State ME Provide a copy of the most current deed. 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. Owen Park Associates, LLC mattk@reliant-partners.com Name 4004 Barrett Dr., STE. 204 E-mail Address 4004 Barrett Dr., STE. 204 Current Mailing Address Current Street Address Raleigh, NC 27609 Raleigh, NC 27609 City State Zip City State ME Telephone (919) 235-8304 Fax Number 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip Telephone. City Fax Number State Zip 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). 1 agree to provide corrected information should there be any change in the information provided herein. Matt Kirkpatrick Type or print name Signat e Managing Member Title or Authority Date 1, IV) a(-, Or Y' e chn," t'S , a Notary Public of the County of WG State of North Carolina, hereby certify that ��)CA� 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 ��_day of A 20 �- MARJORIE A. IAMBRAKIS NOTE%RY PUBLIC WAF KE COUNTY, NC My Coin Expires 6 20 2022 Notary U // My commission expires