NCC220645_FRO Submitted_20220215

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. Cell 7 (MSW Landfill) and Phase 7 (C&D Landfill) Expansion Project
1. Project Name
2. Location of land -disturbing activity: County Buncombe City or Township Alexander
Highway/Street 81 Panther Branch Rd Latitude 35.727226 Longitude-82.630881
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Landfill development
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 46 acres
6. Amount of fee enclosed: $ a,soo (balance owed $1,610) 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dane Pedersen E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax # [phone]
E
Landowner(s) of Record (attach accompanied page to list additional owners):
Buncombe County 828-250-4830
Name Telephone
200 College Street, Suite 300
Current Mailing Address
Asheville, NC 28801
City State
10. Deed Book No. 1851
Current Street Address
Zip City
Page No. 0097
State
828-250-6086
Fax Number
Zip
Provide a copy of the most current deed.
Part B.
I. 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.
Buncombe County [e-mail]
Name E-mail Address
81 Panther Branch Rd
Current Mailing Address
Alexander, NC 28701
Current Street Address
City State Zip City State Zip
Telephone [phone] Fax Number [phone]

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 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.
V)OJ\P . L t r � '—' -
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Signature
Title or Authority
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Date
a Notary Public of the County of 6Wn QvvV2.e
State of North Carolina, hereby certify that ,� '0 �Z_ 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 %AtT day of tick- (2�; 20 2
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Seal
= D. LAMAR JOYNER My commission expires -tea - Zo 23
BUNCOMBE COUNTY
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