NCC230255_FRO Submitted_20230130

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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 N/A in the blank.)
1. Project Name Alamance County MSW Landfill
2. Location of land -disturbing activity: County Alamance City or Township Graham
Highway/Street 2701 Austin Quarter Rd.
Latitude(decimal degrees) 35.94028 ° Longltude(decimai degrees) 79.22611 °
3. Approximate date land -disturbing activity will commence: July 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Borrow Site & Access Ph6
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 35 additional acres
6. Amount of fee enclosed: $3500.00. 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. ($2275(previously submitted) + $1225 = $3500)
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ® No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: Richard Hill E-mail Address: - [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Recorri !attach acnmmnnnicri nnrin +n rc+ ­ 1A;+o­i n,.,.,., 1.
Alamance County
Name
124 W. Elm Street
Current Mailing Address
Graham NC 27253
City State Zip
336-228-1312
Telephone
124 W. Elm Street
Current Street Address
Fax Number
Graham NC 27253
City State Zip
10. Deed Book No. 778 Page No. 496 Provide a copy of the most current deed.

1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Alamance County [e-mail]
Company Name E-mail Address
124 W. Elm Street 124 W. Elm Street
Current Mailing Address Current Street Address
Graham NC 27253 Graham NC 27253
City State Zip City State Zip
Phone: Office # 336-228-1312 Mobile #
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:
Name of Registered Agent
Current Mailing Address
City
Phone: Office #
E-mail Address
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:
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.
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.
Sherry Hook
Type or print name
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Signature
Interim Countv Manager
Title or Authority
1te/®2-
Date
a Notary Public of the County of ax
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged tha a above form was executed by him/her.
Witness my hand and notarial seal, this day of
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