NCC215266_FRO Submitted_20210927

FINANCIAL RESPONSISUTYIOWNERSHIP 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 NIA in the blank.)
Part A. Buncombe Count Solid Waste Management Facility 1. Project Name y y
2. Location of land -disturbing activity: County Buncombe City or Township Alexander
Highway/Street 81 Panther Branch Rd Latitude 35.727226 Longitude-82.630881
3. Approximate date land -disturbing activity will commence: Occurred (12/01 /95)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Landfill development
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 79 acres
6. Amount of fee enclosed: $ 0 (paid previously) 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dane Pedersen E-mail Address Dano,[e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Buncombe County 828-250-4830 828-250-6086
Name Telephone Fax Number
200 College Street, Suite 300
Current Mailing Address Current Street Address
Asheville, NC 28801
City State Zip City State Zip
10. Deed Book No, 1851 Page No. 0097 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 companyorfirm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
Buncombe County [e-mail]
Name
81 Panther Branch Rd
Current Mailing Address
Alexander, NC 28701
City
State Zip
Telephone [phone]
E-mail Address
RECEIVED
Current Street Address
City State - Y SECTION
Fax Number
828-250-5479 ASHEVILLE

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:
_& / k
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Type or print name Title or Authority
�= m PLIAA 4s r
Signature Date !
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I' r—A0116_9 Jcly'48 a Notary Public of the County of UNcp�
State of North Carolina, hereby certify that A&z appeared
personally before me this day and being duly sworn acknowledged that the above form�i����v��
executed by him.
Witness my hand and notarial seal, this 3t 91daY of
p,RY pLj''ti,
Seal D. LAMAR JOYNER
BUNCOMeE COUNTY
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LAND QUALITY SfrCTOt\I
ASHFVILLE
My commission expires 211OZ27