NCC223057_FRO Submitted_20220913

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 Environment and Natural Resources. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
Project Name Park East pad ready site
2. Location of land -disturbing activity: County Wayne City or Township Goldsboro
Highway/Street Gateway Drive River Basin: Neuse
Latitude N 35.3706 Longitude W-77.9241
(Lat and Long given to 4 decimal places it XX.xxxx N,-YY.yyyy W. not XX xx'xx° N, -YY yy' yy" W)
3. Approximate date land -disturbing activity will commence: December 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.5
6. Amount of fee enclosed: 455 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Mark Pope E-mail Address mark.pope0waynegov.com
Telephone [phone] Cell # [phone] Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Wayne County Develo ent Alliance Inc.
Name
P.O. Box 10397
Current Mailing Address
Goldsboro NC 27532
City State Zip
[phone] [phone]
Telephone Fax Number
208 Malloy Street, Suite C
Current Street Address
Goldsboro NC 27534
City State Zip
10. Deed Book No. 3280 Page No. 376 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Wavne County Developent Alliance. Inc.
Name
P.O. Box 10397
Current Mailing Address
Goldsboro NC 27534
City State Zip
Telephone [phone]
mark.DoDe &wavneaov.com
E-mail Address
208 Malloy Street, Suite C
Current Street Address
Goldsboro NC 27534
City State Zip
Fax# [phone]

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 Zip
Telephone,
E-mail Address
Current Street Address
City State Zip
Fax#
(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 Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax#
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 by any change in the information provided herein.
Mark Pope President
Type or print name Title or Authority
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Date
a Notary Public of the County of La-'-*:)c�...,^rP
State of North Carolina, hereby certify that yykm_' C_ pe--y-P 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 Gk day of 6 , 20
Seal
My commission expires 0 �. .