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HomeMy WebLinkAboutNCC222395_FRO Submitted_20220712FINANCIAL 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 Westside C&D Landfill — Area 2 Phase 1 Construction 2. Location of land -disturbing activity: County Wilson City or Township Wilson NC 42 East 35.732-77.865 Highway/Street LatltUde(decimal degrees) LOngltUde(decimal degrees) 3. Approximate date land -disturbing activity will commence: May 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Landfill Expansion 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.97 Acres 6. Amount of fee enclosed: $ 500 . 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. $1500 previously submitted with original plan 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Andy Davis E-mail Addressadavis@wilson-nc.com Phone: Office # 252-339-2823 Mobile # 9. Landowner(s) of Record (attach accompanied page to list additional owners): Wilson County 252-339-2823 Name PO Box 1728 Current Mailing Address Wilson, NC 27894 City State 10. Deed Book No. 2891 Phone: Office # Mobile # 2201 Miller Rd. South Current Street Address Wilson, NC 27893 Zip City Page No. 453-455 State Zip 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). Wilson County Company Name PO Box 1728 Current Mailing Address Wilson, NC 27894 City State Zip Phone: office # 252-339-2823 dstinagle@wilsoncountync.gov E-mail Address 2201 Miller Rd. South Current Street Address Wilson, NC 27893 City State Zip Mobile # 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. Denise Stinagle or print name Sign County Manager Title or Authority 701 I, N ��. \��Q . �YVi f�►� a Notary Public of the County of A)tSVN State of North Carolina, hereby certify that Dpn� RIL , gsAaQl . appeared personally before me this day and being duly sworn acknowledged that thi above form was executed by him/her. Witness my hand and notarial seal, this � day of 20 �O; Notary NOTARY Z" My commission expires -Ai> P _ UBtIC 2 /pllryrIi n!I