NCC221934_FRO Submitted_20220606

FINANCIAL 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 Environment and Natural Resources. (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 Winding Pine Pump Station
2. Location of land -disturbing activity: County Chatham City or Township Cary
Highway/Street Winding Pine Trail Latitude 35.8540 longitude -78.9066
3. Approximate date land -disturbing activity will commence: 07/05/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.) -. Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.4
6. Amount of fee enclosed: $ 390 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 Enclosed =
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Daniel Blake E-mail Address [e-mail]
Telephone [phone] Cell # 919-628-2630 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Cary 919-469-4000 NIA
Name Telephone Fax Number
P.O. Box 8005 316 N. Academy Street
Current Mailing Address Current Street Address
Cary, NC 27512-8005 Cary, NC 27513
City State Zip City State Zip
10. Geed Book No. 2237 Page No. 0617 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Crowder Construction Company [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

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
M
Name
E-mail Address
N/A
NIA
Current Mailing Address
Current Street Address
NIA
NIA
City State
Zip City State Zip
NIA
Fax Number NIA
Telephone
(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 L Hansen
[e-mail]
Name of Registered Agent
E-mail Address
6425 Brookshire Boulevard
6425 Brookshire Boulevard
Current Mailing Address
Current Street Address
Charlotte, NC 28216
Charlotte, NC 28216
City State
Zip City State Zip
704-372-3541 NIA
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.
Chris Robards
Type or print name
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Signature
Vice President
Title or Authority
5/19/2022
Date
a Notary Public of the County of
State of North Carolina, hereby certify that Chris Robards appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my
rial seal, this _ Clay of .2022
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