NCC221825_FRO Submitted_20220604

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. Columbus County LCID Landfill
1. Project Name
2. Location of land -disturbing activity: CountyColumbus_City orTownshipWhltevllle
Highway/Street 111 Landfill Road Latitude 34.293 Longitude-78.752
3. Approximate date land -disturbing activity will commence: January 24
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29.0
6. Amount of fee enclosed: $ 2900 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 -Amanda Davis E-mail Address [e-mail]
Telephone [phone] cell 4 910-642-2828 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Columbus County
Name Telephone Fax Number
111 Washington St
Current Mailing Address Current Street Address
Whiteville NC 28472
City State Zip City State Zip
10. Deed Book No. 376 Page No. 362 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.
Columbus County [e-mail]
Name E-mail Address
111 Washington St
Current Mailing Address
Whiteville NC 28472
City
Current Street Address
State Zip City
Telephone [phone] Fax Number
State
Zip

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
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
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.
Chris Nobles Assistant Director
Type or int name
Signature
Title or Authority
02/11/2022
Date
a Notary Public of the County of
State of North Carolina, hereby certify that � yb s no V appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness m han qpo notarial seal, this
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