NCC222677_FRO Submitted_20220810

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 A. Aurora Industrial Park
1. Project Name
2. Location of land -disturbing activity: County Beaufort
Highway/street Hwy 33 Latitude 35.300261
3.
4.
5.
6.
City or TownshipAurora
Longitude-76.785765
Approximate date land -disturbing activity will commence: May 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 19.0
Amount of fee enclosed: $ $1,900.00 . 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 Cliff Williams
E-mail Address [e-mail]
Telephone [phone]
cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Mary Guilford Thompson
Name
Telephone Fax Number
820 Vineyard Drive
Current Mailing Address
Current Street Address
New Bern NC 28562
City State
Zip City State Zip
10. Deed Book No. 1 134
Page No. 467 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.
Town of Aurora
[e-mail]
Name
E-mail Address
PO Box 86
Current Mailing Address
Current Street Address
Aurora NC 27806
City State
Zip City State Zip
Telephone [phone]
Fax Number

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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Telephone
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.
Cliff Williams
Type or print name
Mayor, Town of Aurora
Title or Authority
Signat,6ie o Date
I, ye �
1OV-e4 �—. o rv—s a Notary Public of the County of �,2 -r
State of North Carolina, hereby certify that ��� Wappeared
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 day of r 20 ZI.
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