NCC223315_FRO Submitted_20220929

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name U-5528FA Rosehiil Road Sidewalk
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
S R 1615 35.111059 78.903587
Highway/Street Latitude{decimal degrees} Long ltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: 11-01 -2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.7 Acre
6. Amount of fee enclosed: $ 300 . 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.
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:
NameJohn McNeill E-mail Address [e-mail]
Phone: Office # 910-433-1091 Mobile # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Right of Way 910-364-0601
Name
Current Mailing Address
City State
Phone: Office #
Current Street Address
Zip City
State
Mobile #
Zip
10. Deed Book No. Page No. 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.) lftho company is a sole proprietorship or iftho landownor(s) is
an individual(s), the name(s) of the owners) may be listed as the financially responsible party(ies).
City of Fayetteville
Company Name
433 Hay Street
Current Mailing Address
Fayetteville NC 28301
City State Zip
Phone: Office # 910-433-1091
[e-mail]
E-mail Address
433 Hay Street
Current Street Address
Fayetteville NC 28301
City State Zip
Mobile # N/A
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:
NIA
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:
NIA
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.
NIA
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.
John McNeill
Type or print name
-A A-, O� fzdlz
ignature
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Engineer II
Title or Authority
7/6122
Date
)�ec� 0, N . 'tea tc r- , a Notary Public of the County of _ sci rtps (m
State of North Carolina, hereby certify that -ahn W. /Uckcr j I appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this I
ra N. Parker
otary Public
Sampson County
North Carolina
day of A was � , 20 0?
N t ry
My commission expires—)i g ? L2p 2