NCC223361_FRO Submitted_20220927

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 NIA in the blank.)
Part A.
Project Name CMSD — WWTP Berm Improvements
Location of land -disturbing activity: County Pitt City or Township Grifton
Highway/Street Wiley Gaskins Road (SR 1910) Latitude 35'21'31.64"N Longitude 77°24'57,33"W
Approximate date land -disturbing activity will commence: Fall 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.50 acres
6. Amount of fee enclosed: $520.00. 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 Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William A. Larsen, P.E. E-mail Address [e-mail]
Telephone [phone] Cell # N/A Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Contentnea Metro olitan Sewera a District 252-524-5584
Name Telephone
252-524-3491
Fax Number
P.O. Box 477 900 Wiley Gaskins Road _
Current Mailing Address Current Street Address
Grifton NC 28530 Grifton NC 28530
City State Zip City State Zip
10. Deed Book No. W43 Page No. 156 List 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.
Contentnea Metropolitan Sewerage District
Name
P.O. Box 477
Current Mailing Address
crosd 100Ca.embarigmail.com
E-mail Address
900_Wiley Gaskins Road
Current Street Address
Grifton NC 28530 Grifton NC 28530
City State Zip City State Zip
Telephone [phone] Fax Number 252-524-3491

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 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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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.
Charles M. Smithwick, Jr.
Type r print name
Signature
District Manager _
Title or Authority
Date
I, �at �� G • yc� , a Notary Public of the County of
State of North Carolina, hereby certify that G1n �c1 _ �u,nt�rh+`-f — 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 �`3kday of , 20 � k
Notary
Seal
My commission expires 7-07-