NCC221828_FRO Submitted_20220513

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 Water Treatment Plant Improvements Phase 2, DWI No. H-SRP-D-17-0076
2. Location of land -disturbing activity: County Chatham City or Township Siler City
Highway/Street Water Plant Road Latitude N 35.76045 Longitude W-79.46229
3. Approximate date land -disturbing activity will commence: February 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Water Plant Imp`
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.47 ACt
6. Amount of fee enclosed: $ 130.00 + 70.00 . 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mr. Roy Lynch E-mail Address., [e-mail]
Telephone [phone] Cell # Fax #t
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Siler City 919-742-4731 919-663-3874
Name Telephone Fax Number
_P.O. Box 769 311 North Second Avenue
Current Mailing Address Current Street Address
Siler City NC 27344 Siler City NC 27344
City State Zip City State Zip
10. Deed Book No. 433 Page No. 448
Deed Book No. 88 Page No. 0271 Provide a copy of the most current deed.
Part B.
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 listen' as the financially responsible party.
Town of Siler City rl nch silerci .or
Name A E-mail Address
P.O. Box 769 311 North Second Avenue
Current Mailing Address Current Street Address
Siler City NC _ _ 27344 Siler City_ NC 27344
City State Zip City State Zip
Telephone [phone] Fax Number 919-663-3874

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.
Roy Lynch
Type or print name
Signature
Town Manager
Title or Authority
Date
el-13 -ao
1, �Cllaora EA Crhrinrl CZ a Notary Public of the County of
State of North Carolina, hereby certify that P\ Ou 4nc,-h appeared
personally before me this day and being duly sworn acknow edged that the above form was executed
by him.
Witness my hand and notarial seal, this J day of So -nuCi U , 20_�,a
This instrument tags been preaudited
in the manner required by the
Local Government Budget Seal
and iscal.Control
Finance Officer
i/I3�cm'�
Date
�PN
cP o
Z 4f oOTA/p�, N
Z
r �
ram, �X1 �dY 6, CDT
co� ���•.
Notary
My commission expires , ,,0 6