NCC221292_FRO Submitted_20220404

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. Henry Fork River Park
1. Project Name
2. Location of land -disturbing activity: County Catawba City or Township Hickory
Highway/Street Sweet Bay Ln Latitude N 35"42'08.04" Longitude 81 °22'43.3"
3. Approximate date land -disturbing activity will commence: September 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational Park
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 7.76
6. Amount of fee enclosed: $ 520.00 . 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 Kelly Winkler E-mail Address [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Hickory 828-323-1042
Name Telephone Fax Number
76 North Center Street 76 North Center Street
Current Mailing Address Current Street Address
Hickory NC, 28601 Hickory NC, 28601
City State Zip City State Zip
10. Deed Book No. 77 Page No. 184 Provide a copy of the most current deed.
Part B.
1. Company(les) 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.
City of Hickory, NC [e-mail]
Name
76 North Center Street
Current Mailing Address
Hickory NC, 28601
City State
Telephone [phone]
E-mail Address
76 North Center Street
Current Street Address
Hickory NC, 28601
Zip City
State
Fax Number 828-323-1042
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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
City
Current Street Address
State Zip City
Telephone 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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone 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). I agree to provide
corrected information should there be any change in the information provided herein.
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Type or print pamp Title or Awfhoritv
Signature - Date .I
M(,a Notary Public of the County of a_
State of North Carolina, hereby certify that i rIV-1-611 wooappeared
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 ! Wl� day of �� , 20 _ZO
Notary
�6� 0 ' My commission expires 2 22—
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