NCC222737_FRO Submitted_20220801

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. Phillippie LCID Landfill
1. Project Name pp
E
3.
4.
5.
6.
7
Location of land -disturbing activity: CountyAlamance City or TownshipCoble
Highway/street Kimesyille Road Latitude 35.995236 Longitude-79.501316
Approximate date land -disturbing activity will commence: Upon Permitting
Purpose of development (residential, commercial, industrial, institutional, etc.): ICID Landfill
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.5 acres
Amount of fee enclosed: $ 600.00 . 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).
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 Kenneth Phillippie E-mail Address [e-mail]
Telephone [phone] cell # 336-266-0522 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Kenneth Phillippie 336-266-0522 n/a
Name Telephone Fax Number
3736 Clapp Mill Road 3736 Clapp Mill Road
Current Mailing Address Current Street Address
Burlington, NC 27215 Burlington, NC 27215
City
10. Deed Book No. 341 7
State Zip City
Page No. 706
State
Zip
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.
Kenneth Phillippie [e-mail]
Name
3736 Clapp Mill Road
Current Mailing Address
Burlington, NC 27215
City
E-mail Address
3736 Clapp Mill Road
Current Street Address
Burlington, NC 27215
State Zip City
Telephone [phone]
Fax Number n/a
State
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:
n/a
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
n/a
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.
Type or print name Title or Authority
Z A 2- -2-Z—
Signature Date
I, di4d 4 hrka a Notary Public of the County of
State of North Carolina, hereby certify that jl,ltl hi%�%1iie appeared
personally before me this day and being duly sworn ackrYoWledged that the above form was
executed by him. / r
Witness my hand and notarial seal, this ita day of )" Jo r# 20 jJ
[JANET A BARKER Nota
Seall'40TARY PUBLIC
ALAMANCE COUNTYMy commission expiresNorth Carolina
ission Expires Februpo!%.2023