NCC221508_FRO Submitted_20220420

00""ECEIVED
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT F E 8 _ ZP02
No person may initiate an land -disturbing activity on one or more acres as covered b t t i
Y Y g v Y �� REGIONAL OFFICE
form and an acceptable erosion and sedimentation control plan have been completed and approve l
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Aberdeen Soccer Park Grading and Erosion Control
2. Location of land -disturbing activity: County Moore City or Township Aberdeen
Highway/Street: US Hwy 15/501 Latitude 35.1159 Longitude-79.4320
3. Approximate date land -disturbing activity will commence: March, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Recreational
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 22.80 acs.
6. Amount of fee enclosed: $1,885.00 . 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 Paul Sabiston E-mail Address psabiston@.townofaberdeen.net
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Aberdeen, a North Carolina municipal corp 910-944-1115
Name Telephone Fax Number
P.O. Box 785
Current Mailing Address
Aberdeen NC 28315
City State Zip
10. Deed Book 5245 Page No.
Part B.
26
115 N. Poplar St
Current Street Address
Aberdeen NC 28315
City State Zip
Provide a copy of the most current deed.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Town of Aberdeen, a North Carolina municipal core sabiston()townofaberdeen.net
Name E-mail Address
P.O. Box 785 115 N. Poplar St
Current Mailing Address Current Street Address
Aberdeen NC 28315
city State Zip
Aberdeen NC 28315
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
State Zip
E-mail Address
Current Street Address
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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
city State Zip
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 by any change in the information provided herein.
Paul Sabiston
Type or Print Nam
PCMA
Signature
Town Manager _
Title or Authority
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oat
I, _ T 1 eQ inn a iaS a Notary Public of the County of rn e-
State of North Carolina, hereby certify that i�Q +� S 4L b on 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 day of Jan cLa Ir1 20 a a
1-� A R Y Notary
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