NCC221947_FRO Submitted_20220526

FINANCIAL RESPONSIBILITY/OWNERSHIP 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. Providence Boulevard Road Improvements - Phase 2
1. Proiect Name
2. Location of land -disturbing activity: County Johnston City or Township Selma
Highway/Street us 70-70A/SR2374/SR2305 Latitude 35.5187 Longitude-78.2856
3. Approximate date land -disturbing activity will commence:4/4/22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Roadway
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.0
$500: 6 ac disturbed area previously paid
6. Amount of fee enclosed: $ The application fee of $1 00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $goo)
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kevin Dougherty E-mail Address [e-mail]
Telephone [phone] cell # 412-302-2415 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Eastield Associates, LLC
919-965-5661 919-965-8568
Name
Telephone Fax Number
101 S. Raiford St, suite 200
101 S. Raiford St, suite 200
Current Mailing Address
Current Street Address
Selma, NC 27576
Selma, NC 27576
City State Zip
City State Zip
10. Deed Book No. See separate page Page No.
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.
Eastfield Associates, LLC
[e-mail]
Name
E-mail Address
101 S. Raiford St, suite 200
101 S. Raiford St, suite 200
Current Mailing Address
Current Street Address
Selma, NC 27576
Selma, NC 27576
City State Zip
City State Zip
Telephone [phone]
Fax Number 919-965-8568

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:
N/A
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:
N/A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City
Telephone
State Zip City
Fax Num
State Zip
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.
Kevin M. Dougherty
Type or1print nP,._
nature
Title or Authority
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personally before me this day and being duly sworn acknowle' ed that t e above form was
executed by him.
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Witness my hand and notarial seal, this day of axr 20
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