NCC223036_FRO Submitted_20220825

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 Name Mazarick Park Tennis Center
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street 730 Filter Plant Road Latitude 35.067832 Longitude-78.899303
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Parks and Recreation
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 11.05 acres
6. Amount of fee enclosed: $1200. The application fee of $100.00 per acre (rounded up to the next acre)
is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
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 Michael Hammersley E-mail Address [e-mail]
Telephone [phone] Cell # same Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
City of Fayetteville
Name
433 Hay Street _
Current Mailing Address
Fayetteville NC 28301
910-433-1949
Telephone
Current Street Address
10. Deed Book No. 5270 Page No. 282 Provide a copy of the most current deed.
Part B.
Fax Number
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.
C=T'f
Name
433 &-c
Current Mailing Address
pp'-eet'rlrt1x4G� '.1C, gig 3o1
City State Zip
Telephone 90- Lt53- 156%_1
niicVl4c° (0SOA @�4 efi�e�li (te-AC• OJ
E-mail Address
Current Street Address
Irp, Ev 3 L Le- �'C- 933
City State Zip
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
Telephony 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.
M=GN A ELL Gs$sov_A
Type or print name
gnature
PARKS J, RGGR AT O —J>G2eGTO
Title or Authority
a- ALA aoa
Date
(� V� i_Yl It 5 a Notary Public of the County of r A- I± 0 )d
State of North Carolina, hereby certify that r r L1 C, O, G i bS0 r 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 day of , 2g 22
TAMMY KNOWLES Notary
No AR PUBLIC
Cu t�1nd Coun, 1
North Carolina l�Oq My commission expires -f
My Commission Expires