NCC222877_FRO Submitted_20220830

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 NIA in the blank.)
Part A. Robeson County Landfill LCID and Borrow Area Expansion
1. Project Name
2. Location of land -disturbing activity: CountyRObeSOn City or Township St. Pauls
Highway/Street NC-20 Latitude 34.79263 Longitude-78.90834
3. Approximate date land -disturbing activity will commence: January, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial (Landfill)
1.3 AC Added (Total of 30.2 AC) 7. S. 01
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): + 1.3
�f
6. Amount of fee enclosed: $ 00 The application fee of $100.00 per acre o.Z
(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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Gene Walters E-mail Address [e-mail]
Telephone [phone] Cell # Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Robeson County 910-671-3000 910-671-3010
Name Telephone Fax Number
701 N. Elm Street 701 N. Elm Street
Current Mailing Address Current Street Address
Lumberton NC 28358 Lumberton NC 28358
City State Zip City State Zip
10. Deed Book No. 2028 Page No.181-186 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.
Robeson County Solid Waste [e-mail]
Name E-mail Address
PO Box 366 Landfill Road 246 Landfill Road
Current Mailing Address Current Street Address
St. Pauls NC 28384 St. Pauls NC 28384
City State Zip City State Zip
Telephone [phone] Fax Number 910-865-2560

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
City
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
Gene Walters
Aor Vac
e
Signature
Director, Robeson County Solid Waste
Title or Authority
l �o d
Dat
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I, a Notary Public of the County of Q
State of North Carolina, hereby certify that E Jd �ers 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 J61 day
My commission expi
20A/