NCC223183_FRO Submitted_20220922

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.
1. Project Name Sanitary Sewer Rehabilitation, Phase 3
2. Location of land disturbing activity: County Stanly City or Township Albemarle
Highway/Street Various Latitude 35.344825 Longitude-80.220142
3. Approximate date land disturbing activity will commence: Monday, April 4 . 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
Sewer System Rehabilitation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.2 acres
6. Amount of fee enclosed: $650. 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
Rob McIntyre, P.E. E-mail Address robcDLKCengineering.com
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Albemarle [phone] [phone]
Name Telephone Fax Number
PO Box 190 144 North Second Street
Current Mailing Address Current Street Address
Albemarle NC 28002 Albemarle NC 28001
City State Zip City State Zip
10. Deed Book No. N/A Page No. NIA 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.
City of Albemarle. Michael Ferris
City Manager mferrisOalbemarlenc.gov
Name E-mail Address
PO Box 190 144 North Second Street
Current Mailing Address Current Street Address
Albemarle NC 28002 Albemarle NC 28001
City State Zip City State Zip
Telephone [phone] Fax Number [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:
NIA
Name
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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
Telephone.
State
E-mail Address
Current Street Address
Zip City State Zip
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.
Michael Ferris
TVm
Signature
Cily Manager
Title or Authority
inn Z�, ZD Z Z
Date
I, 41idel
v F Aye-PL �Yt a Notary Public of the County of S^TGtr1 i�
State of North Carolina, hereby certify that 1' lNGke ` r t S 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 day of Y1-LAGi 20 0;2
Notary
Seal � S-9
My commission expire