NCC242347_FRO Submitted_20240822

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. Abbott Road Environmental LCID Landfill
1. Project Name
Vance orTownsh. Henderson
2. Location of land-disturbing activity: County City p
Highway/Street Abbott Road Latitude 36.2582 Longitude-73.3326
3. Approximate date land-disturbing activity will commence:J u l.7 15, 2024
Industrial
4. Purpose of development(residential,commercial,industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
29.7
3,000.00 The application fee of $100.00 per acre
6. Amount of fee enclosed: $ pP
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac= $900.00).
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
Alan Faulkner E-mail Address [e-mail]
Telephone[phone] Cell# N/A Fax# N/A
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Alan Faulkner [phone] N/A
Name Telephone Fax Number
1415 Abbott Rd N/A
Current Mailing Address Current Street Address
Henderson, NC 27537 N/A
City State Zip City State Zip
10. Deed Book No. I 365 Page No.523-525 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 may be listed as the financially responsible party.
Faulkner Grading and Landscaping, Inc. [e-mail]
Name E-mail Address
PO Box 2258 45 Faulkner Town Rd
Current Mailing Address Current Street Address
Henderson, NC 27536 Henderson, NC 27537
City State Zip City State Zip
Telephone(252) 430`9525 Fax Number N/A

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:
N/A N/A
Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
N/A
Telephone Fax Number N/A
(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:
Alan Faulkner [e-mail]
Name of Registered Agent E-mail Address
PO Box 2258 45 Faulkner Town Rd
Current Mailing Address Current Street Address
Henderson, NC 27536 Henderson, NC27537
City State Zip City State Zip
Telephone [phone] N/A
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.
Alan Faulkner President
Type o print name j Title or Authority
Signature Date
Il
1, 1A0.0VIe.. F:ITN)ryNos , a Notary Public of the County of 611-V\i\r) it-
State of North Carolina, hereby certify that o-Ki appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness notarial seal, this \1+11 day of ‘•-k-- ,
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My commission expires
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