NCC221009_FRO Submitted_20220414

FINANCIAL RESPONSIBILITYIOWNERSHIP 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. Wilkes Road Yard Waste Facility
1. Project Name
2. Location of land -disturbing activity: CcuntyCumberland City or Township Fayetteville
Highway]street Wl lkes Rd Latitude 35.02 Longitude -78.88
3. Approximate date land -disturbing activity will commence: J a n . 1 , 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 24
6. Amount of fee enclosed: $ 1 3560 . 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:
NameAmanda Bauer E-mail Address [e-mail]
Telephone [phone] cell 4 NIA Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Cumberland County 910-321-6920
Name Telephone
PO Box 1829 771 Wilkes Rd
Current Mailing Address
Current Street Address
N/A
Fax Number
Fayetteville, NC 28302 Fayetteville, NC 28306
city State Zip City State Zip
10. Deed Book No. 3422 Page No. 0607 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.
Cumberland County Solid Waste [e-mail]
Name
698 Ann Street
Current Mailing Address
Fayetteville, NC 28301
City
E-mail Address
698 Ann Street
Current Street Address
Fayetteville, NC 28301
State Zip City
Telephone [phone]
State
Fax Number910-321-6840
WE

(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
Telephone N/A 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 Assurned Name, if the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N/A N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City State
Telephone. N/A
E-mail Address
N/A
Current Street Address
_ N/A
Zip City
Fax Number N/A
State Zip
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 rint am Title or A thority
Signature Dat
I, M�' I � 0� �5 a Notary Public of the County of
State of North Carolina, hereby certify thatappeared
personally before me this day and beingAjknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this _0V d of IV 0-t� 20 a1
MYRA M. BROOKS7
NOTARY PUBLIC Nota
Chur��erland County rY
mirth Carolina
My Commission Expires 7-`� My commission expires 3