NCC232607_FRO Submitted_20230829

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 N/A in the blank.)
Part A.
1. Project Name Snow Hill Road Pump Station - Force Main
2. Location of land-disturbing activity: County Durham City or Township Durham
Highway/Street 5090 Denfield St. Latitude 36.075224°N Longitude 78.887411°W
3. Approximate date land-disturbing activity will commence:August 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.):SS Force Main
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):4.2
6. Amount of fee enclosed: $845 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 ✓
8 Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Vincent Chirichella E-mail Address [e-mail]
Telephone[phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Durham [phone] [phone]
Name Telephone Fax Number
101 City Hall Plaza 101 City Hall Plaza
Current Mailing Address Current Street Address
Durham NC 27701 Durham NC 27701
City State Zip City State Zip
10. Deed Book No.376 Page No 588 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):
Durham County Engineering and Environmental [e-mail]
Services
Name E-mail Address
5926 NC Highway 55 5926 NC Highway 55
Current Mailing Address Current Street Address
Durham NC 27713 Durham NC 27713
City State Zip City State Zip
Telephone[phone] Fax Number(919) 544-8590

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_
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.
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Signature Date
I, CORINNA, G. SoIgFRS , a Notary Public of the County of 17uQE4kM
State of North Carolina, hereby certify that \JINCtS'JT Ct-t\R‘CMt tom 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 (pT0 day of JUt_\.t , 20 23
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I Corinr Somers 1
0 Notary Public I My commission expires PPRIL 210, 2025
Orange County,North Carolina
My Commission Expires LI /210/is