NCC220649_FRO Submitted_20220208

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 Lumberton Asphalt Plant
2. Location of land -disturbing activity: County Robeson City or Township Lumberton
Highway/Street 211 Old Crawford Rd. Latitude 34.5892 N Longitude 79.0825 W
3. Approximate date land -disturbing activity will commence: 2/1 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areasf: 45.0 acres
6. Amount of fee enclosed: $ 4,500 The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 William Holmes E-mail Address [e-mail]
Telephone. Cell # 910-635-7016 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Barnhill Contracting Company
Name Telephone Fax Number
PO Box 7948
Current Mailing Address Current Street Address
Rocky Mount NC 27804
City State Zip City State Zip
10. Deed Book No. 2322 Page No. 65-69 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.
Barnhill Contracting Company
Name E-mail Address
PO Box 35376 1100 Robeson Street
Current Mailing Address Current Street Address
Fayetteville NC 28303 Fayetteville NC 28305
City State Zip City State Zip
Telephone_91 0-488-1319 Fax Number 910-488-5673

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:
ivame 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 City State Zip
Telephone_ 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.
William Holmes
Type or print name
Signature
Area Manager
Title or Authority
Date
I , . JT C1�C 14�� , a Notary Public of the County of Cho "Yvt 6Us
State of North Carolina, hereby certify that W T-LLa:IA Y►'\ H 0 L-W\6 S appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness m�a��`''ri ' '.seal, this �z
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