20090006 Ver 5_Fin Respon/Ownership Form 071315_20150713

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e -mail and /or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name Stoney Crepk Stream EnhancP;Jrient Pr(11P.Ct — Phase II
2. Location of land - disturbing activity: County Wavne City or Township Goldsboro
Highway /Street East Rovall Avenue Latitude 35.385570 Longitude - 77.954470
3. Approximate date land- disturbing activity will commence: Fall 2015
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Stream enhancement
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 195.00 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 No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land- disturbing activity:
Name Martv Anderson E -mail Address manderson @aoldsboronc.aov
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Citv of Goldsboro 919 -580 - 4_3.7.7
Name Telephone Fax Number
PO Box A 200 North Center Street
Current Mailing Address Current Street Address
Goldsboro NC 27533 Goldsboro NC 27530_
City State ZIP City State Zip
10. Deed Book No.1063_ Page No. 665 Deed Book No.0715 Page No. 268 Provide a copy of
the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land- disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet): c} ✓;,.�
City_ of Goldsboro - Attn: Scott A. Stevens [e-mail]
Name E -mail Address
200 North Center Street 200 North Center Street
Current Mailing Address Current Street Address
Goldsbor_Q NC 27530 Goldsboro NC 27530
City State Zip City State Zip
Telephone [phone] Fax Number 919 -580 -4344

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
Current Mailing Address
City State
Telephone
E -mail Address
Current Street Address
Zip City
Fax Number
State Zip
(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
Current Mailing Address
City State
Telephone
E -mail Address
Current Street Address
Zip City
Fax Number
State Zip
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.
Scott A. Stevens
Type r print n me
S}gnature
Citv Manaaer
Title or Authority
L- 17-1 -5
Date
-------------------------- - - - - --
I, j G, vrci G z , a Notary Public of the County of ,I(;-
State of North Carolina, hereby certify that Sc a � A. s' AL e 'j e:" c' appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this
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teal
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1 day of ), . -, , 20 r �_
Notary
My commission expires 'l -31 -L 1,