NCC222188_FRO Submitted_20220613

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. Johnston County Buffalo WWPS and FM Upgrade
1. Project Name
2. Location of land -disturbing activity: County Johnston City or Township Smithfield
Highway/Street Varies (see map) Latitude35°30'56"N Longitude780 20'59.3"W
3. Approximate date land -disturbing activity will commence: February 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Infrastructure
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas ):7.9 AC
6. Amount of fee enclosed: $ 0 . 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
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chandra Farmer, P.E. E-mail [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Public Roads and RM & Easements
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. NA Page No, NA 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.
Johnston County [e-mail]
Name E-mail Address
P.O. Box 1049 207 E. Johnston Street, Courthouse B-206
Current Mailing Address Current Street Address
Smithfield, NC 27577 Smithfield, NC 27577
City State
Teleohone(919) 989-5100
Zip
City
State
Fax Number [phone]
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 State
Telepho
E-mail Address
Current Street Address
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
Telephone
E-mail Address
Current Street Address
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 ag
the authority to execute instruments for the Financially Responsible Person). I agree e
corrected information should there be any change in the information provided herein. ,._-1
Rick Hester
Type or
Signatu
County Manager
Title or Authority
Z
Date
I, __ ?oo_'` 0.. G • �j o n C4, a a Notary Public of the County of Y oh n _S+O n
State of North Carolina, hereby certify that R-. CA, -Y. 1A eS-�er appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a_1 day of T_e.NOrwar. , 20 as
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Seal
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Notary
My commission expires 10 - 1 - () al.,