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HomeMy WebLinkAboutNCC221828_FRO Submitted_20220513FINANCIAL 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., rlynch_@silercity.org Telephone 919-742-4731 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 919-742-4731 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