NCC230997_FRO Submitted_20230414

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.)
P1. Part A.roject Name Austin Chaney Convenience Center
2. Location of land-disturbing activity: County Union City or Township Monroe
Highway/Street 2125 Austin Chaney Latitude 35.03881 Longitude-80.45840
3. Approximate date land-disturbing activity will commence:February 2022
Solid Waste Convenience Center
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8
6. Amount of fee enclosed: $800 . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Chris Medlin E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Union County Public Works
Name Telephone Fax Number
500 North Main Street
Current Mailing Address Current Street Address
Monroe NC 28112
City State Zip City State Zip
10. Deed Book No.246 Page No 334 Provide a copy of the most current deed.
Part B. 330 070
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.
Union County Public Works [e-mail]
Name E-mail Address
500 North Main Street
Current Mailing Address Current Street Address
Monroe NC 28112
City State Zip City State Zip
Telephone [phone] Fax Number

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: j
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.
Ronald Gilkerson Solid Waste Director
Type or rint name Title or Authority
-07/.1..-_,
Signature Date
III,Jrh r"_. R \1 O rtve- , a Notary Public of the County of u+tri or\
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State of North Carolina, hereby certify that or1A." 8l�itio+rsUrN appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness m Oa �►wrial seal, this day of kvueic..1 , 20 a
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Notary
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