NCC222739_FRO Submitted_20220816

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.
1 Project Name4_Duplin County Animal Shelter
2. Location of land -disturbing activity: County Duplin City or Township Kenansville
Highway/Street 287 Fairgrounds -Dr-, Kenansville, NC Latitude 34 95194 N Longitude 77 98420 VV
3 Approximate date land -disturbing activity will commence: October 29- 2021
4 Purpose of development (residential, commercial, industrial, institutional, etc ): Commercial
5 Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.4
6 Amount of fee enclosed: $ 325.00 . 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 Joe Newburn E-mail Address joe newburn duol,ncount nc.com
Telephone [phone] Cell # Same Fax # N/A
9 Landowner(s) of Record (attach accompanied page to list additional owners)
County of Du lin 910-296-2104 N/A
Name Telephone Fax Number
PO Box 950 224 Seminary Street
Current Mailing Address Current Street Address
_Kenansville NC 28349 Kenansville_ NC 28349
City State Zip City State Zip
10 Deed Book No. 1264 Page No 305 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.
County of Du lin _ dbrinson du lincount nc.com
Name E-mail Address
PO Box 950
Current Mailing Address
224 Seminary Street
Current Street Address
Kenansville NC 28349 Kenansville NC 28349
City State Zip City State Zip
Telephone [phone] 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 Mailing Address
E-mail 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.
Davis Brinson County Manager
Type r print name Title or Authority
Signature Date
I. a Notary Public of the County of lie\
State of North Carolina, hereby certify that ba V i s rt n.so -I-- 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 Z I day of I1 act �a.r , 20 Z. `
•-' 4 TA fo
v: N Ry►� r
a= 0.r
• '
� ;mil 8 L! G
,
's w ti• �•.
ota ry
My commission expires q — / 1— 26
E2