NCC231462_FRO Submitted_20230516

NC Department of
Environmental quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM JAN 0 7 2>22
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION Winston-S Iem
No person may initiate any land-disturbing activity on one or more acres as covered by the AMOR:RAW-ken
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.
1. Project Name: Bermuda Run Juniper Pump Station & Forcemain
2. Location of land-disturbing activity: County of Davie City or Town: Town of Bermuda Run
Highway/Street 217 Juniper Cir_Latitude 35.9950067 Longitude -080.4229349
3. Approximate date land-disturbing activity will commence: 01/11/21
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Public Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.8 ac
6. Amount of fee enclosed: $1,750 Express+ $700 Req. The Express Permitting application fee is a dual
charge. The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition,the Express Permitting supplement is$250.00 per acre up to eight acres,after which
the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is$2,900).
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 : John C. Grey, PE E-mail Address:jgrey(dgrevenqineerina.com
Telephone: [phone] Cell #: [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Town of Bermuda Run [phone]
Name Telephone Fax Number
120 Kinderton Blvd., Suite 100 120 Kinderton Blvd., Suite 100
Current Mailing Address Current Street Address
Bermuda Run NC 27006 Bermuda Run NC: 27006
City State Zip City State Zip
10. Plat Book No. 13 Page Nos. 499, 500, 501
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.
Town of Bermuda Run, Lee Rollins Irollins(a�townofbr.com
Name E-mail Address
120 Kinderton Blvd., Suite 100 120 Kinderton Blvd., Suite 100
Current Mailing Address Current Street Address
Bermuda Run NC 27006 Bermuda Run NC 27006
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Grey Engineering, Inc. igreyna greyengineerinq.com
Engineering firm or other consultant E-mail Address
John C. Grey, PE [phone]
Individual contact person (type or print) 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.
Lee Rollins Bermuda Run Town Manager
Type or print name Title or Authority
/i 9'-- i J Gl r �r + ,70,2 2.
Signature Date 7
I, C f\� t 4. � e, a Notary Public of the County of r?_
State of North Carolina, hereby certify that 'RD I I. appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
no
Witness my hand and notarial seal, this Ul ' ` day of 20
ota
Seal
My commission expires 3) `7 ' 0 10