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HomeMy WebLinkAboutNCC222716_FRO Submitted_20220729FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 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 Duality. 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 NIA in the blank.) Part A. 1 2 3 Project Name CAT - Sanford P D Location of land -disturbing activity: County Lee City or Township Sanford Highwayrstreet Womack Road Latitude(decimal degrees) 35.5498 Longitude(dacimal degrees} Approximate date land -disturbing activity will commence: July 2022 -79.1689 4. Purpose of development (residential, commercial, industrial, institutional, etc.). Industrial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 13.00 ACreS S. Amount of fee enclosed $3,300.00 . The Express Permitting application fee is a dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900), Checks should be addressed to NCDEQ. 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: NameTyrell C. Britt E-mail AddressT__C_Britt@cat.com Phone: Office # (919) 777-2010 Mobile # (919) 795-4139 9. Landowner(s) of Record (attach accompanied page to list additional owners): Caterpillar Inc. (919) 777-2010 Name Phone: Office # Mobile # 100 NE Adams Street 5000 Womack Road Current Mailing Address Peoria, IL 61629-5425 Current Street Address Sanford, NC 27330 city State Zip City State Zip 10. Deed Book No. 1397 Page No. 235 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 sore 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). Caterpillar, Inc. Company Name 5000 Womack Road Current Mailing Address Sanford, NC 27330 T_C_6ritt aacat.com E-mail Address 5000 Womack Road Current Street Address Sanford, NC 27330 City State Zip City State Zip Phone., Office # (919) 777-2010 Mobile # (919) 795-4139 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 (d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: McKim & Creed, Inc. Engineering firm or other consultant Don Bataille Individual contact person (type or print) dbataille@mckimcreed.com E-mail Address (919) 233-8091 Phone- Office # Mobile # 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 individuals} 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. Mi(WF,W, 44vLeipAj Type or print name Signature 1)I P-WVle _ rU(;pt V M6MT 91.-EIV&I W6124 I)& Title or Authority 4 Z/�Zzz Date A� 4 +-v 1 t'1 ��T k-a Notary Public of the County, of [1 X ,J l State of North Carolina, hereby certify that G1� lL�d� appeared personally before me this day and being duly sworn acknowledged that the above fgrm was executed by him/her. Witness my hand and notarial seal, this Seal =EMulhollan—d— r'tandCber 27, 2026 ay of , 2a 9Z a ary r� My commission expire f 2-7 262 �