NCC222395_FRO Submitted_20220712

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Westside C&D Landfill — Area 2 Phase 1 Construction
2. Location of land -disturbing activity: County Wilson City or Township Wilson
NC 42 East 35.732-77.865
Highway/Street LatltUde(decimal degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: May 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Landfill Expansion
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.97 Acres
6. Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ. $1500 previously submitted with original plan
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Andy Davis E-mail [e-mail]
Phone: Office # 252-339-2823 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wilson County 252-339-2823
Name
PO Box 1728
Current Mailing Address
Wilson, NC 27894
City State
10. Deed Book No. 2891
Phone: Office # Mobile #
2201 Miller Rd. South
Current Street Address
Wilson, NC 27893
Zip City
Page No. 453-455
State
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Wilson County
Company Name
PO Box 1728
Current Mailing Address
Wilson, NC 27894
City State Zip
Phone: office # 252-339-2823
[e-mail]
E-mail Address
2201 Miller Rd. South
Current Street Address
Wilson, NC 27893
City State Zip
Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, 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
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Denise Stinagle
or print name
Sign
County Manager
Title or Authority
701
I, N ��. \��Q . �YVi f�►� a Notary Public of the County of A)tSVN
State of North Carolina, hereby certify that Dpn� RIL , gsAaQl . appeared personally
before me this day and being duly sworn acknowledged that thi above form was executed by him/her.
Witness my hand and notarial seal, this � day of 20
�O; Notary
NOTARY Z"
My commission expires -Ai>
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