NCC230784_FRO Submitted_20230322

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. South Selma Regional Pump Station & Forcemain
1. Project Name
2. Location of land -disturbing activity: County Johnston City or Township Selma
Highway/Street HWY 70 Latitude Longitude
3. Approximate date land -disturbing activity will commence: 10/1 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): ±1 0
6. Amount of fee enclosed: $ 650.00 . 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 I Kevin Dougherty E-mail Address [e-mail]
Telephone [phone] cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached listing
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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.
Eastield Associates, LLC [e-mail]
Name E-mail Address
101 S Raiford St, Suite 200 101 S Raiford St, Suite 200
Current Mailing Address Current Street Address
Selma NC 27576 Selma NC 27576
City State Zip City State
Telephone [phone] Fax Number 919-965-8568
Zip

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.
Kevin Dougherty
Cype or tint nam�, % - ` Title or Authority
ignature V Date
1---------------- --------------------------------------------------------------------------------------------------------------------
SaIlk f Y a) n
a Notary Public of the County of b h nS61
State of North Carolina, hereby certify that lC_Vt' n � �v� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a
IISHA PEARSON
SeNOTARY PUBLIC
Johnston County
North Carolin h
My Commission Expires a,
day of J 20 c
Notary
My commission expires 3�

SOUTH SELMA REGIONAL PUMP STATION
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
LISTING OF IMPACTED PINS
• 14N99006F — Donald Carol Hull, Phyllis Larue Hull
o 260412-85-8481
• 14057027G —Johnston Square Associates LLC
o 260412-86-2024
• 14057009 — Nell M Howell Revocable Trust
o 260407-57-1688
• 14044022A — Paul H Howard
o 260408-88-3830
• 14M10089 — Paul H Howard
o 260408-89-3389
• 14044022 — Paul H Howard
o 260408-89-4810
• 14001015D — Robert W Williams, Jane Williams Davis
o 260520-70-7294
• 14054010P — Sysco Food Services of Ral LLC
o 260504-60-4924
• 14057009Y —Town of Selma
o 260504-62-5795
• 14057012C — County of Johnston
o 260504-62-8239
Saved Parcel Information
40 Delete Checked ,4 Delete All
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Actions
Tag
NCPin
ilapsheet No
Owner Name 1
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12P111019
261400-42-4067
2614
EASTFIELD ASSOCIATES LLC
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12h112004K
261414-44-1722
261414
EASTFIELD ASSOCIATES LLC
L .t (a
12M12003
261414-43-2419
261414
CROCKER, JOSEPH MELVILLE
G t 0
141112001C
261414-33-1808
261414
ABDALLA, MICHAEL J SR.
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141_10014I
261414-23-9958
261414
ABDALLA, MICHAEL J SR.
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12h112004F1
261414-34-2420
261414
P & L PROPERTIES OF JOHNSTON, LLC