NCC221202_FRO Submitted_20220329

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. White Hat Stream and Wetland Mitigation Project
1. Project Name
2. Location of land -disturbing activity: County PerqulmanS City or Township Hertford
Highway/Street Suttons Lane Latitude 36.173499 Longitude-76.331442
3. Approximate date land -disturbing activity will commence: June 1, 2022
0
Purpose of development (residential, commercial, industrial, institutional, etc.): Mitigation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 65
6. Amount of fee enclosed: $ 6,500 . 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 Paul Dunn E-mail Address [e-mail]
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
The William and Ethel Chappell Revocable Living Trust
Name
Telephone Fax Number
135 Lauren Lane
Current Mailing Address
Current Street Address
Hertford NC 27944
City State Zip
City State Zip
10. Deed Book No. 520 Page No. 531 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.
Resource Environmental Solutions, LLC
[e-mail]
Name
E-mail Address
3600 Glenwood Ave, Suite 100
3600 Glenwood Ave, Suite 100
Current Mailing Address
Current Street Address
Raleigh NC 27612
Raleigh NC 27612
City State Zip
City State Zip
Telephone [phone]
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 State Zip
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:
Daniel Ramsay
Name of Registered Agent
3600 Glenwood Ave, Suite 100
Current Mailing Address
Raleigh NC 27612
City
State Zip
Telephone [phone]
[e-mail]
E-mail Address
3600 Glenwood Ave, Suite 100
Current Street Address f
Raleigh
City
Fax Number
NC 27612
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). I agree to provide
corrected information should there be any change in the information provided herein.
Type or. print name Title or Authority i
Signature Date
I, AM14 S ` —,a Notary Public of the County of W OJ—\-e�
State of North Carolina, hereby certify that Vl It I t • P_/AM�w'l 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
AMY STALEY --
NOTARY PUBLIC
Johnston County
North Carolina
MMy 0pRiiili�Bak Expires Sept. 4, 2023
day of 20 1
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Notary / 1
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My commission expires �L'