NCC240953_FRO Submitted_20240410

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 and/
or fax information unavailable, place N/A in the blank.)
Part A.1. Project NameTown of Vass Phase 2 Sewer Extension Project
2. Location of land-disturbing activity: County Moore City or TownshipVass
Highway/Street Various Latitude 35.2527 Longitude-79.2783
3. Approximate date land-disturbing activity will commence:August 2020
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Sewer EXtensiot
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 20.6
6. Amount of fee enclosed: $ 17365.00 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
Randy Gould E-mail Addressrgould@moorecountync.c
Telephone[phone] Cell# NA Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See Attached
Name Telephone Fax Number
Current Mailing Address Current Street Address
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) 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 solo proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Moore County [e-mail]
Name E-mail Address
PO Box 1927 5227 US 15
Current Mailing Address Current Street Address
Carthage NC 28347 Carthage NC 28347
City State Zip City State Zip
Telephone[phone] Fax Number910-947-1992
3

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.
Rand Goul Public Works Director
Typ r ri me Title or uth ri<t t
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Signature Date
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one tic kel Li , a Notary Public of the County of Moore.
State of North Carolina, hereby certify that k 7?L(.�i�( appeared
personally before me this day and being duly sworn ��cknowledged that the above form was
executed by him.
dAdWitness mX,Mncl,and notarial seal, this day of U�- , 20 2,0
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NOTARY
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County of Moore, PO Box 905, Carthage, NC 28327 Check Number: 00413068
Invoice Date Number. • •• • b4 lPtlon Invoice Amount
05/06/2020 VASS PH 2 PERMIT VASS PH 2 SEWER EROSION CONTRO $1,365.00
Comment:PLEASE SEND CHECK TO PUBLIC WORKS/UTILITIES
DIVISION,ATTN:MARY MUNZ,MARY TO GIVE CHECK TO BRIAN
PATNODE,BRIAN TO MAIL CHECK WITH DOCUMENTS
E
�er�d"or No,. .. =w=: :_f Y, ,,i, Ve dor Name.
.TI:_. .. . Chei�`Nd Glleck'Date ...`,: . Gheck Amotirii'�'•::v
21457 NC DEQ 00413068 05/07/2020 $1,365.00
, •• • .'• FIRST t3ANK7 Neoder Check Check "
TROY,NC 273 umber• Date 'i
o e'" Number"
•C.Qunty of Moore 21457 05/07/2020 00413068 631
F, CaSag 905 • ",.. . VOID 60`0AYS FROMTE.O DAF ISSUE
Carthage NC::28327;: a
_ 1,365.00
Pay One Thousand Three Hundred•:Sixty:Five D.ollars:and:;00 cents<*•''**;*•:
;, ,„
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• •A • AUTHOR . V SIGNAT
:..To The NG DEQ,{.: ..:
26:GRE. lV STR ET.
• :. ITMEtt'EV.LL•E;N!C: 836 5094 s ' _
't • AU'tH0(zlga
v .: E .RE UIRED BY
< THtS DISBUR$l=MENT'HA$.BE�N ApPftOV.4 A.,$ Q
{e qy;y`.' ` LAND CONTROL ACT•
LOCAL GDVERNMENY 8l1DGET"l tSCA