NCC230699_FRO Submitted_20230329

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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.)
Part A.
1. Project Name Cleveland County Justice Center - Early Utility Relocations & Grading
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
N/A
2. Location of land -disturbing activity: County Cleveland City or Township City of Shelby
Justice Place 35.2913 81.5364
Highway/Street Latltude(decimal degrees) Longltude(decimal degrees)
3. Approximate date land -disturbing activity will commence: April 1, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Government
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.4 acres
6. Amount of fee enclosed: $ 700 . 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.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed m No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kerri Melton, Ass't County Mgr E-mail Address [e-mail]
Phone: Office # 704-484-4816 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cleveland County 704-484-4816
Name
Kerri Melton
Current Mailing Address
PO Box 1210
City State
10. Deed Book No. 1437
Phone: Office #
311 E. Marion Street
Current Street Address
Shelby NC
Zip City
Page No.1137
State
704-692-6505
Mobile #
28150
Zip
Provide a copy 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 orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Cleveland County
Company Name
PO Box 1210
Current Mailing Address
Shelby NC 28151-1210
[e-mail]
E-mail Address
311 E. Marion Street
Current Street Address
Shelby NC 28150
City State Zip City State
Phone: Office # 704-484-4816 Mobile # [phone]
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 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.
Kerri Melton Assistant County Manager
Typ or print name Title or Authority
h,ft4/L f
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Si Pture Date
-----------------------------------------------------------------------------------------------------------------------------
I, �h(( 5 a Notary Public of the County of aaf�
State of North Carolina, hereby certify that ►' j �� 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 l 20 -0 �
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Notary
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Continued from Items 9 & 10 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:
Same as above
Name
Current Mailing Address
City State
Deed Book No. 1 799
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
Phone: Office #
Current Street Address
Mobile #
Zip City State Zip
Page No. 613 Provide a copy of the most current deed.
Phone: Office #
Current Street Address
State Zip City
Page No.
Mobile #
State Zip
Provide a copy of the most current deed.
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
City
Deed Book No.
Current Street Address
State Zip City
Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 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.
Same as above
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 #