NCC231409_FRO Submitted_20230512

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 address
or phone number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Fayetteville Annexation Ph V Project IX Constr.Area 25 Lake Rim Estates&Oak Meadow
2. Location of land-disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street Gooden Dr. Latitude(decimaldegrees)35.041388°N Long itude(decimal degrees) -79.0438°W
3. Approximate date land-disturbing activity will commence: October 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 17.12
6. Amount of fee enclosed: $ $1800.00 . 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 ® No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Allan J. Riddle, P.E. E-mail Address allan.riddleAfaypwc.com
Phone: Office# 910-223-4785 Mobile#
9. Landowner(s) of Record (attach accompanied page to list additional owners): See attached list
Fayetteville PWC 910-223-4736
Name Phone: Office# Mobile#
955 Old Wilmington Rd. 955 Old Wilmington Rd.
Current Mailing Address Current Street Address
•
Fayetteville NC 28302 Fayetteville NC 28302
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) 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).
Fayetteville PWC allen.riddle(a�faypwc.com
Company Name E-mail Address
955 Old Wilmington Road 955 Old Wilmington Road
Current Mailing Address Current Street Address
Fayetteville NC 28302 Fayetteville NC 28302
City State Zip City State Zip
Phone: Office# 910-223-4785 Mobile#
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)

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.
Misty Manning, PE Water Resources Engineer Manager
Type or print name Title or Authority
� r I CC-A 7/ 1 2v z.-
Signature / Date
I, g1Iz abelt, 7" VGSSP. . , a Notary Public of the County of Cu,m i'4n�
State of North Carolina, hereby certify that t S -t. IM.A n n I n appeared
personally before me this day and being duly sworn acknowledged that'Jthe above form was
executed by him/her.
Witness my hand and notarial seal, this [Cf day of WA,I11 , 20 aa.
ELIZABETH T VASSER Not
Nt9taty Public
Cumberland County Mycommission
North Carolina expires 3 u ne a a a va 3