NCC223960_FRO Submitted_20221129

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: Leith Creek WWTP Influent Pump Station Improvements
2. Location of land -disturbing activity: County: Scotland City or Township: Laurinbura
Highway/Street: Hall Street Latitude: 34.765526' Longitude:-79.446225'
3. Approximate date land -disturbing activity will commence: Summer 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): WWTP Renovation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4 acres
6. Amount of fee enclosed: $260.00 . 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: Charles D. Nichols, III, City of Laurinbura E-mail Address: cnicholsa-laurinbura.ora
Telephone: [phone] Cell #: N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Laurinbura [phone] N/A
Name Telephone Fax Number
P.O. Box 249 303 West Church Street
Current Mailing Address Current Street Address
Laurinbura NC 28277 Laurinbura NC 28352
City State Zip City State Zip
10. Deed Book No. 5J Page No. 136 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 Laurinbu
Name
P.O. Box 249
Current Mailing Address
Laurinbura NC 28277
City State Zip
cnicholsa-laurinbura.ora
E-mail Address
303 West Church Street
Current Street Address
Laurinbura NC 28352
City State Zip

Telephone: [phone] Fax Number: NIA
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
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:
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.
Charles D. Nichols, III City Manager
Type or r t na Title or Authority
Si nature Date
I,�Ch a Notary Public of the County of Jc 0-9
State of North Carolina, her certify that ILL-� appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness
r�yEhailApnd notarial seal, this -If day of l 20
Lina p
m �efflT. • o
My commission expires /-CO
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