NCC230370_FRO Submitted_20230213

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 ofEnvironmental Quality. Submit the completed form tothe appropriate
Regional Office. (Please typo or print and, if the question is not applicable or the e-mail address or phone
number is unavailable, place N/4 in the blank.)
Part A.
1. Project Name Piney Green Volunteer Fire FleOf
2. Location of!mnd'dioturbing activity: Countv O[ls|C]VV City orTo«vnshi |ackSC}[l\/'||e
yJ��c��� 1��/�D 34.7336 77.3200
Highwmy/Stnaa ' ^�^`'' ~ ' LaUtudew"m"�u"o=°"�`Longi�udew"m�"/o"v�""L_____
3. Approximate date land -disturbing activity will commence: Ja[]UaFV 2023
4. Purpose of development (reoidenho|, oommeroio|, industrial, institutional, etc.): |nst'fiJf'o[lE3|
��
5. Total acreage d�hudbedoruncovered (including off -site borrow and waste anaao}:`-'^^
G. Amount offee enclosed: 1050 (express) The application fee of $100.00per acre (rounded
uptuthe next acre) ioassessed without aceiling amount (Examp|a:8.10-ocn*application fee io$8OO).
Checks should be oddn*000d to NCDEO. '
l Has onerosion and sediment control plan been filed? Yes Enclosed 2] No F]
[i Person bzcontact should erosion and sediment control issues arise during land -disturbing activity:
Name Steve Sanchez
��D-�A1_�O��
Phone: Office `° �`'' �"^^� Mobile #same
Ei ofRecord (attach accompanied page bolist additional ownero):
Piney Green Volunteer Fire O8oL'Inc. 910L581_2083 same
Name
2720 Piney Green Road
Current Mailing Address
Jacksonville NC, 28544
Phone Offioa# Mobile #
2720 Piney Green Road
Current Street AddressMidway Park, Park /WC,28544
City State Zip City State Zip
5��74 �29��32
10. O�B� P��N °="= Provide acopy 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.) 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).
Piney Green Volunteer Fire Dept., Inc.
Company Name
2720 Piney Green Road
Current Mailing Address
Jacksonville NC, 28544
City State
Phone: Office # 910-581-2083
[e-mail]
E-mail Address
2720 Piney Green Road
Current Street Address
Midway Park, NC 28544
Zip City
Mobile # Same
State
Zip
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 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:
Name of Registered Agent
E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

(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.
Steve Sanchez
Type or print name
A&� -
ign `, re
President
Title or Authority
Da
1'101 0PP O- , a Notary Public of the County of
�
State of North Carolina, hereby certify that Skue, ' G) X 6ez 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. day of D gUA-Y Ibk c , 20 ca
wo�'�►t�Peef°°°, n
'Ft PINO J
r01 on
w% % Notary
'p�tARy
00 I z e My commission expires ffloo ` co t'p
'�i°o Ow GGJ�����

Continued from Items 9 & 90 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed
to list all landowners.
Landowner 2 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 3 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.
Landowner 5 of Record:
Name
Phone: Office # Mobile #
Current Mailing Address
Current Street Address
City State
Zip
City State Zip
Deed Book No.
Page No.
Provide a copy of the most current deed.

Continued from Item 9 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 4 Name
E-mail Address
'
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State
Zip
Phone: Office #
Mobile #

Piney Green Volunteer Fire Department
The Piney Green Volunteer Fire Department proposes to develop a 2.34 acre tract located
between Piney Green Road and Rocky Run Road in the White Oak Township. The tract
spans the distance between NCSR 1460 (Piney Green Road) and NCSR 1413 (Rocky Run
Road) and the proposed development will have an entrance at each highway. The proposed
development includes a 11,781 sf building with associated parking, an outside equipment
area & dumpster pad.
The site is currently vacant. Site topography is generally flat to gently sloping (0 - 2%). The
site generally drains towards the north to a wetland area on the adjacent property
The project site is located in the White Oak River basin and drains to an Unnamed Tributary
of Mott Creek (C;NSW). The proposed development activities are high density (percent
impervious > 24 %); therefore, stormwater treatment facilities are required. The attached
Stormwater Plan includes a Constructed Stormwater Wetland (designed to meet current
SCM Design Manual specifications. Stormwater runoff from the site will be diverted (via
swales and inlet structures) into a system of pipes discharging into the forebay of the
Constructed Wetland.
There is an amount of offsite runoff from approximately 11.5 acres south of the site and
draining northwards towards the site . This offsite runoff will be independently collected and
conveyed across the site via a system of pipes and swales and will NOT be diverted'io the
proposed treatment system.
The site contains primarily Forestone loamy fine sand at 0 — 2% grades. Proposed ESC
devices include silt fence around the project perimeter, construction entrances, inlet
projection and sediment storage in the proposed wetland excavation (dewatered by
skimmer device). All collected sediment will be removed upon completion of construction
and prior to placing the constructed wetland into final service.
1
Water and sewer service to be provided by 0 NWASA. Sewer Service will require
installation of a Wastewater Pumping Station and 1.5 "forcemain (service) connecting to an
existing 10" forcemain along Rocky Run Road.