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HomeMy WebLinkAboutNCC241637_FRO Submitted_20240614 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Hurricane Florence Jimmies Creek Damage Repairs 2. Location of land-disturbing activity: County Craven City or Township New Bern Rude decimal Various Various Lon degrees)Various Highway/Street Latltude(decimal degrees) g ( 3. Approximate date land-disturbing activity will commence:April 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.): Maintenance 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 13.5 6. Amount of fee enclosed: $ 1400 . 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). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Luke Baker E-mail Address Ibaker@trccompanies.com Phone: Office# 919-827-0864 Mobile# 910-723-5158 9. Landowner(s)of Record (attach accompanied page to list additional owners): City of New Bern 252-636-4000 N/A Name Phone: Office# Mobile# PO BOX 1129 1004 S Glenburnie Rd Current Mailing Address Current Street Address New Bern, NC 25863 New Bern, NC 28560 City State Zip City State Zip 10. Deed Book No.Various Page No.Various Provide a copy of the most current deed. 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). City of New Bern N/A Company Name E-mail Address PO BOX 1129 1004 S Glenburnie Road Current Mailing Address Current Street Address New Bern, NC 28563 New Bern, NC 28563 City State Zip City State Zip Phone: Office# 252-363-4000 Mobile# N/A 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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Name of Individual to Contact(if Registered Agent is a company) (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: Name of Registered Agent E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Name of Individual to Contact(if Registered Agent is a company) (c) If the Financially Responsible Party is engaging in business under an assumed name, give name under which the company is Doing Business As. If the Financially Responsible Party is an individual, General Partnership, or other company not registered and doing business under an assumed name, attach a copy of the Certificate of Assumed Name. Company DBA Name 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. Foster Hughes City Manager Type or print name Title or Authority N.- Signature Date I, 1), e Pyiir lv:5 , a Notary Public of the County of aphie,nl State of North Carolina, hereby certify that I L teJL ,�ly 1? appeared personally before me this day and being duly sworn acknowledgedr�_ that the above form was executed by him/her. Witness my hand and notarial seal, thisal1 day of �� , 0,23 `,`rrrrrrrNrlrrrgr�r,,I 10[ff./ � (�JJ �,•�`` �1,E PARS ''�•,, Notary-P ' x�%'%2 Mycommission expiresfJ2&i G 1 0 02 NOTARY PUBLIC ' U 0 # 'VT _ Aril 9,2�`L•�„�, N c '''i,rrurrerrrtt��`' Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile#