NCC231095_FRO Submitted_20230419

Check if this project is ARPA-funded TI
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. ProjectName C&D Land fill, lnc. -Phase 3
±lf 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)`
2. Location of land-disturbing activity: County
Recycling Lane Latitude(decimal
3. Approximate date land-disturbing activity will
City or Township
35.62(
Greenville
Longitude(decimal
commence:April 24, 2023
-77.182
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Industrial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amountoffee enclosed: S 1200 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. Hasan erosionandsedimentcontrol plan been filed? Yes E Enclosed I \ NO I
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name April Whitehurst Haltigan [e-mail]
phone: office # 252-752-8274 Mobile # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C&D Landfill, lnc.
Name
802 Recycling Lane
Current Mailing Address
Greenville NC 27834
Crty
10. Deed BookNo.2624
State Zi p
Page NO.
252-752-8274 n/a
Phone: Office # Mobile #
same as mailing
Current Street Address
City
762-765
State Z i p
Provide a copy of the most ourrent deed.