NCC220840_FRO Submitted_20220302

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.
1. Project Name Nash County Animal Facility
2. Location of land -disturbing activity: County Nash City or Township Oak Level
Highway/Street 3656 Eastern Ave Latitude 35.97134 Longitude 77.90211
3. Approximate date land -disturbing activity will commence: Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.63
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 Andrews Stocks E-mail Address [e-mail]
Telephone [phone] ^ Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nash County 252-459-9800
Name Telephone Fax Number
120 W Washington St, Ste 3072
Current Mailing Address Current Street Address
Nashville NC 27856
city State Zip City State Zip
10. Deed Book No. 3105 Page No. 342 Provide a copy of the most current deed.
Part B.
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.
Nash County [e-mail]
Name E-mail Address
120 W Washinaton Street
Current Mailing Address
Nashville
City
Current Street Address
NC 27856
State Zip City
State
Zip

Telephone_ 252-459-9800 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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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, 1 �01 Z V-IN4
Type or print name{ I Title or Authority
�_24
Date
1, 7:SqON S , a Notary Public of the County of
State of North Carolina, hereby certify that _Zce-. I.C'4 :b 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 86- day of R>cCew� �-c r' , 20 31
JANICE EVANS
NOTARY PUBLIC Notary
Seal HALIFAX COUNTY N.C. 1
My commission expires