NCC223070_FRO Submitted_20220830

FINANCIALS 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.
Project Name: Harnett Regional Jetport: Apron Expansion
2. Location of land -disturbing activity: County Harnett City or Township N/A
Highway/Street Airport Road Latitude 35.3735°N Longitude-78.73691W
3. Approximate date land -disturbing activity will commence: September 1, 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Airport
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7
6. Amount of fee enclosed: $ 455 . The application fee of $66.00 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 X Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Barry A. Blevins E-mail Address bblevins EDhamett.org
Telephone [phone] Cell # 910-494-1616 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
County of Harnett
Name
P.O. Box 759
Current Mailing Address
Lillington NC 27546
City State Zip
910-893-7555 910-814-2660
Telephone Fax Number
420 McKinney Parkway
Current Street Address
Lillington NC 27546
City State Zip
10. Deed Book No. 685 Page No. 774-775 Provide a copy of the most current deed.
Part D.
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 ormanager maybe listed as the financially responsible party.
Harnett County (Paula K. Stewart, Manager) pstewartRharnett.org
Name E-mail Address
P.O. Box 759
Current Mailing Address
Lillington NC 27546
City State Zip
420 McKinney Parkway
Current Street Address
Lillington NC 27546
City State Zip

Telephone [phone] Fax Number 910-814-2660
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 Blame. 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 Num
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.
P&,A I a k � �� ��- CO L& &
Type or print name Title or Author ty
S-X
Signature Date
---------------------------------------- -------------------------------------------------------------------------------------------
1, fyp Q-,/_ , a Notary Public of the County of ' N OAAL6
State of North Carolina, hereby certify thatappeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness�raa �i' tarial seal, this ,
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