NCC223711_FRO Submitted_20221031

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. The 203 Project
1. Project Name
2. Location of land -disturbing activity: County Orange City or Township Town of Carrboro
Highway/Street sGreensboro Street (8R1919) Latitude 35054'33.65"N Longitude790 4'18.79"W
3. Approximate date land -disturbing activity will commence: O 1 /0 1 12 022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public - Mixed Use
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.25 acres
6. Amount of fee enclosed: $ 130 . 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 Ben Schmadeke E-mail Address [e-mail]
Telephone [phone] Cell # 919-637-8056 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Carrboro 919-918-7333
Name Telephone Fax Number
301 W Main Street 301 W Main Street
Current Mailing Address Current Street Address
Carrboro, NC 27510 Carrboro, NC 27510
City State Zip City State Zip
10. Deed Book No. 5582 Page No. 486 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.
Town of Carrboro
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip
City State Zip
Telephone Fax Number

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
Part is a Corporation, give name and street address of the Registered Agent:
NA
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.
Arche L. McAdoo Chief Finance Officer
Type t name Title or Authority
.� i i /n9on9 i
Signature Date
I, _ MA KS14A ice- ATE , a Notary Public of the County of 6 9AM &i
State of North Carolina, hereby certify that _
personally before me this day and being
executed by him.
A rzoq E L. A4C Vivo appeared
duly sworn acknowledged that the above form was
�D Witness my hand and notarial seal, this day of�/. _J�0VeU;,0 , 20ft.),4
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tart'
MAIM PATE
NOTARY PUBLIC My commission expires
ORANGE COUNTY, NC
COMMISSION EXPIRES JUNE 20, 2024