NCC221961_FRO Submitted_20220526

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name North Durham WRF Process Improvement Phase 2 Project
2. Location of land -disturbing activity: County Durham City or Township Durham
Highway/Street 1900 E Club Blvd Latitude 36.0276 Longitude -78.8608
3. Approximate date land -disturbing activity will commence: 10/18/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site barrow and waste areas): 6.8
6. Amount of fee enclosed: $ 455.00 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gabel Barrows E-mail Address [e-mail]
Telephone [phone] Cell # 919-576-4747 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Durham 919-560-4381 NIA
Name Telephone Fax Number
100 City Hall Plaza 100 City Hall Plaza
Current Mailing Address Current Street Address
Durham, NC 27701 Durham, NC 27701
City State Zip City State Zip
10. Deed Book No. 107 Page No. 192 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.
Crowder Construciton [e-mail]
Name E-mail Address
1111 Burma Dr 1111 Burma Dr
Current Mailing Address Current Street Address
Apex, NC 27539 Apex, NC 27539
City State Zip City State Zip

Telephone [phone] Fax Number NIA
(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:
Lynn Hansen [e-mail]
Name of Registered Agent E-mail Address
6425 Brookshire Blvd 6425 Brookshire Blvd
Current Mailing Address Current Street Address
Charlotte, NC 28216 Charlotte, NC 28216
City State Zip City State Zip
Telephone [phone] Fax Number NIA
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering Firm or other consultant E-mail Address
Individual contact person (type or print) 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.
Type or print name Title or Authority
L I �—
Signature Date
a Notary Public of the County of " _i,
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness me'`ann,� l �+` eal, this day of �` 20��'
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