NCC222173_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. West New Bern - Phase 2
1. Project Name
2. Location of land -disturbing activity: County Craven City or Township New Bern
Highway/Street NC Hwy. 43 Latitude35.127222 Longitude-77.113333
3. Approximate date land -disturbing activity will commence: May 1, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 40 acres
6. Amount of fee enclosed: $ 4,000.00 . 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 Scott T. Anderson, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # 252-258-0734 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Weyerhaeuser NR Company N/A
Name Telephone Fax Number
2626 Glenwood Ave, Ste 550 2626 Glenwood Ave, Ste 550
Current Mailing Address Current Street Address
Raleigh NC 27608 Raleigh NC 27608
City State Zip City i State Zip
10. Deed Book No. 2687 Page No. 0346 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.
Weyerhaeuser NR Company [e-mail]
Name
1785-B Weyerhaeuser Road
Current Mailing Address
Vanceboro, NC 28586
City State
Telephone [phone]
E-mail Address
1785-B Weyerhaeuser Road
Current Street Address
Vanceboro, NC 28586
Zip City State Zip
Fax Number

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 E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
Timothy T. Jackson Director
Type or print name Title or Authority
&8c'rcc C ,1 7.,11.z0 Z�
Signature Date
I, (�Z O) Go rl In o v- , a Notary Public of the County of ��-
f(ov ►`da
State of North Carolina, hereby certify that �t a+ �-/ J [� appeared
personally before me this day and being duly sworn ack owledged that the above form was
executed by him.
Witness my hand and notarial seal, this Z 1 day of
i*r .., GAIL O'CONNOR
MY COMMISSION / GG 924
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