NCC222652_FRO Submitted_20220802

FINANCIAL 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 and/
or fax information unavailable, place N/A in the blank.)
Part P oject Name Twin 24" Raw Water Transmission Mains Replacement Project
2. Location of land -disturbing activity: CountyNew Hanover City or Township Wilmington
Highway/Street """ MUS 421 a North Terminal Road Latitude 34.2608 N Longitude 77.968664 W
3. Approximate date land -disturbing activity will commence: September 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 16
6. Amount of fee enclosed: $ 1,040 . 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:
Name Frank Styers E-mail Address [e-mail]
Telephone [phone] cell # N/A Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners):
See attached list
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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.
Cape Fear Public Utility Authority [e-mail]
Name
235 Government Center Drive
Current Mailing Address
Wilmington NC 28403
City
State Zip
Telephone [phone]
E-mail Address
235 Government Center Drive
Current Stre6f Addi'eS6'-""
Wilmington NC, 28403
City State Zip
Fax Number N/A

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 State
Telephone
E-mail Address
Current Street Address
Zip 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
Current Mailinq Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
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.
Frank Styers
Type or print name
;�4 4j. c/! S .4-0
Si nature
Deputy Executive Director
Title or Authority
/"lDt•� l �� 2 CJ Z
Date
a Notary Public of the County of 1'Q r�cQ�f
State of North Carolina, hereby certify that S I es- appeared
personally before me this day and being duly sworn ac nowled ed that the above form was
executed by him.
Witness my hand and notarial seal, this day of , 20 2. l
-- e
Judith Lawton
NOTARY PUBLIC Not
Ponder County, NC
My Commission Expires April 05, 2026 My commission expires O �L