NCC240966_FRO Submitted_20240507

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 Name P.O. Hoffer Water Treatment Facility Glenville Lake Water Treatment Facility Reliability Improvements
2. Location of land-disturbing activity: County Cumberland City or Township Fayetteville
Hoffer Drive 38.0811 N 78.8676 W
Highway/Street Filter Plant Drive Latitude 35.0689 N Longitude 78.8954 W
3. Approximate date land-disturbing activity will commence: August, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.5 acres
6. Amount of fee enclosed: $ 260 . 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 Chris Smith E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
PWC - City of Fayetteville, NC [phone]
Name Telephone Fax Number
955 Old Wilmington Road 508 Hoffer Drive
Current Mailing Address Current Street Address
Fayetteville NC 28301 Fayetteville NC 28301
City State Zip City State Zip
894 573
10. Deed Book No. 5270 Page No. 282 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 sole
proprietorship the name of the owner or manager maybe listed as the financially responsible party.
PWC- City of Fayetteville, NC [e-mail]
Name E-mail Address
P.O. Box 1089 955 Old Wilmington Rd.
Current Mailing Address Current Street Address
Fayetteville NC 28302-1089 Fayetteville NC 28301
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
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.
Misty M. Manning Engineer Manager
Type or print name Title or Authority
4)(0;6A ‘,/h/
Signature 1 Date
I, lbt'r✓ VriSSe �' , allotaryPublicoftheCountyof C.Ul`'b�'r'�`1-
State of North Carolina, hereby certify that N1'S 4-1 PA N\( n n i n!j 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 1- day of ��tAa r , 20 �-I
ELIZABETH T VASSER
Notary Public 1 Notry
Cumbe8 County TN North Carolina My commission expires ,J0ne 01� aOJ