NCC240661_Updated FRO_20240418

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, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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: Bertie County RWS - Lewiston Woodville Community Water System Replacement
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name below under which
you applied for funding through the Division of Water Infrastructure (DWI).
Is Project ARPA Funded ARPA Project Name ARPA Project#
Yes Lewiston Woodville Community Water VUR-D-ARP-0042
System Replacement-Water District
No. 4
2. Location of land-disturbing activity: County: Bertie City or Township: Roxotel
Highway/Street: 104 W Church St Latitude: 36.123010 Longitude:-77.176260
3. Approximate date land-disturbing activity will commence: 1/14/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Other: Utility
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.00
6. 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).
7. Has an erosion and sediment control plan been filed? Yes-Will be Mailed or Hand-Delivered
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name: W Landon Younce E-mail Address: [e-mail]
Phone: [phone] Mobile:
9. Landowner(s)of Record:
Landowners of Record
Name Email Business Phone Mobile Phone
Bertie County I juan.vaughan(@bertie.nc.gov 1- 252 -794-5300
Physical Address Mailing Address
Street 1 city State Zip Street 1 city State Zip
106 Dundee St. Windsor North 27983 PO Box 530 Windsor North 27983
Carolina Carolina

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).
Primary Financially Responsible Part
Company Name I Email I Business Phone Mobile Phone
Bertie County I [e-mail]. ov 1- 252 -794-5300
Physical Address Mailing Address
Street 1 city State Zip Street 1 City State Zip
106 Dundee St. Windsor North 27983 PO Box 530 Windsor North 27983
Carolina Carolina
Additional Financially Responsible Parties
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:
Registered Agent Information
Name Email Business Phone Mobile Phone
Ph sical Address Mailing Address
Street 1 City State Zip Street 1 City State Zi
(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:
North Carolina Agent Information
Name Email Business Phone Mobile Phone
Ph sical Address Mailing Address
Street 1 City State Zip Street 1 City State Zi
Engine rin /Consultin Firm Information
Name Email Business Phone Mobile Phone
Green Engineering I. ounce reenen .corn 1- 252 -237-5365
Ph sical Address Mailing Address
Street 1 City State Zip Street 1 City State Zi
303 Goldsboro Wilson North 27893 PO Box 609 Wilson North 27894
Street East Carolina Carolina

Additional Details
1. Stream Classification: C: Aquatic Life, Secondary Contact Recreation, Fresh water; SW: Swamp Waters
2. Was Express Review Requested: No
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.