NCC221759_FRO Submitted_20220518

RECEIVE®
OD9
NOV 2 2 IMANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
SEMI-R
oom` � t t I ing activity on one or more acres as covered by the Act before this
h 1i o 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 NIA in the blank.)
Part A. Clinton - Sampson County Airport - Runway 24 Obstruction Removal . Project Name
2. Location of land -disturbing activity: County Sampson City or Township Clinton
Highway/Street Airport Rd Latitude 34-58-54.62N Longitude 78-21-24.85W
3W,9��g IApproximate date land -disturbing activity will commence: February 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.07
6. Amount of fee enclosed: $ 1,365 . 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 x Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Caleb Williams E-mail Address CWilllams0avConinC.Com
Telephone[phone] Cell # 434-942-4029 Fax #
9. . Landowner(s) of Record (attach accompanied page to list additional owners):
Sampson County/City of Clinton 910-385-9040 910-592-7242
10
Name
406 County Complex Road
Current Mailing Address
Clinton, NC, 28328
City
State Zip
Telephone Fax Number
406 County Complex Road
Current Street Address
Clinton, NC, 28328
City
Deed Book No. 2054 Page No. 977
State
Zip
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.
Sampson County & City of Clinton
Name
E-mail Address
406 County Complex Road 406 County Complex Road
Current Mailing Address Current Street Address
Clinton NC 28328 Clinton N.0 28328
City State Zip City
Telephone [phone]
State
Zip
Fax Number 910-592-7242

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:
NIA
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:
NIA
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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 be any change in the information provided herein.
Tom Hart
Type or print name j
�. 1-i
Signature
I
State of North Carolina, hereby certify that _
personally before me this day and being
City of Clinton - City Manager
Title or Authority
I I
Date
a Notary Public of the
%Vk appeared
sworn acknowledged the t above form was
executed by him. 4
Witness my hand and notarial seal, this day
Elaine F. Hunt
yQTiARY PUBLIC Notary
IROJon County
North Carolina M commission
My Commission Expires September 24, 202$ y expires.