NCC222342_FRO Submitted_20220628

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 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.
Project Name: Lumberton Regional Airport: Schedule I — Partial Parallel Taxiway — Runway 23
Schedule II — Partial Parallel Taxiway — Runway 5
2. Location of land -disturbing activity: County Robeson City or Township Lumberton
Highway/Street US 74 & SR 2513 Latitude 35.3735°N Longitude-78.73691W
3. Approximate date land -disturbing activity will commence: September 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 29.0
6. Amount of fee enclosed: $ 1,885.00 . 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dewayne Allen E-mail Address dewavne.allen(a-ci.lumberton.nc.us
Telephone [phone] Cell # 910-733-3561 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Lumberton
Name
P.O. Box 1388
Current Mailing Address
Lumberton NC 28358
City State Zip
10. Deed Book No. N/A Page No
Part B.
910-671-3811 910-272-1359
Telephone Fax Number
500 N Cedar St
Current Street Address
Lumberton NC 28358
City State Zip.
N/A Provide a copy of the most current deed.
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.
City of Lumberton dewayne.allen(c)-ci.lumberton.nc.us
Name E-mail Address
163 Airport Blvd
Current Mailing Address
Lumberton NC 28358
City State Zip
163 Airport Blvd
Current Street Address
Lumberton NC 28358
City State Zip
Telephone [phone] Fax Number 910-671-3947

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
E-mail 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.
Type or prinf name
Signature
\r\Us\c" m�\
Title or Authority
Date
JQ" ry €D s a Notary Public of the County of �0 �'Jt�y r,\
State of North Carolina, hereby certify that 1 vJ� lJ���� appeared
personally before me this day and being duly sworn ac owledged that the above form was executed
by him.
Witness my hand and notarial seal, this IP 6' day of je�p'Cl � , 20 a'(
Notary
Seal o,
My commission expires l a ±