HomeMy WebLinkAboutNCC222754_FRO Submitted_20220802FINANCIAL 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 N/A in the blank.)
Part A. South Robeson Medical Center
1. Project Name
2.
3.
4.
5.
Location of land -disturbing activity: County Robeson
City or Township Fairmont
HighwaylStreet 210 Walnut St. Latitude 34.495757 Longitude-79.112913
Approximate date land -disturbing activity will commence: March 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.44
6. Amount of fee enclosed: $ 300.00 . The application fee of $100.00 per acre
(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 Jonathan E. Locklear, PE E-mail Address jonathanlocklear q@Ilandj.corn
Telephone 910-774-9306 Cell # _ Fax # 866-649-7235
Landowner(s) of Record (attach accompanied page to list additional owners):
Robeson Health Care Corporation 910-521-2900 ext. 104 910-775-9164
Name
Telephone
Fax Number
60 Commerce Dr. (same)
Current Mailing Address Current Street Address
Pembroke, NC 28372 (same)
City State Zip City State Zip
10. Deed Book No. D 2291 Page No. 855-862 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 Fisted as the financially responsible party.
Robeson Health Care Corporation
Name
jennifer—Mciamb@rhccl.com
E-mail Address
60 Commerce Dr. (same)
Current Mailing Address Current Street Address
Pembroke, NC 28372 (same)
City State Zip City State Zip
Telephone 910-521 -2900 ext. 104 Fax Number 910-775-9164
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:
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
George Timothy Hall gt_hall@ncccl.com
Name of Registered Agent
60 Commerce Dr.
Current Mailing Address
E-mail Address
(same)
Current Street Address
Pembroke, NC 28372 (same)
City State Zip City State Zip
Telephone 910-521-2900 ext. 104 Fax Number 910-775-9164
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.
Jennifer McL.amb VP/Chief Operating Officer
Type or print name Title or Authority
12/22/2021
S atur Date
I, a Notary Public of the County of �o
State of North Carolina, hereby certify that PVlVIt �" C J appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 22 day of T)e_C" , 20_Z�`
BHEWA RECAN
NOTARY PUBLIC
ROBESON COUNTY, NC
N ota
My commission expires + /202.0