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HomeMy WebLinkAboutNCC223115_FRO Submitted_20220902FINANCIAL 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 address or phone number is unavailable, place N/A in the blank.) Part A. 1. Project Name Samaritan Colony Women's Treatment Center 2. Location of land -disturbing activity: County Richmond City or Township Rockingham Highway/Street US Latitude(dec;mal degrees) Long itude(dec;ma; degrees) 220 35.007526-79.770147 3. Approximate date land -disturbing activity will commence: June 15, 2022 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.6 6. Amount of fee enclosed: $ 400 . 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). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Harold Pearson E-mail Address pearson@carolina.rr.com Phone: Office # 910-895-3243 Mobile # 910-995-5323 �i Landowner(s) of Record (attach accompanied page to list additional owners): Samaritan Colony, Inc Name 136 Samaritan Drive Phone: Office # Current Mailing Address Current Street Address Rockingham NC 28379 City State 10. Deed Book No. 1517 Zip City Page No.141 State 910-895-3243 Mobile # Zip Provide a copy of the most current deed. Part B. 1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies). The Samaritan Colony, Inc. pearson@carolina.rr.com Company Name E-mail Address 136 Samaritan Drive Current Mailing Address Current Street Address Rockingham NC 28379 City State Zip City State Zip Phone: Office # 910-895-3243 Mobile # 910-895-8612 Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation control plan and to conduct the anticipated land disturbing aciivity. 2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State business registry, give name and street address of the Registered Agent: Name of Registered Agent Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address of the designated North Carolina agent who is registered on the NC Secretary of State business registry: Name of Registered Agent Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City Mobile # Name of Individual to Contact (if Registered Agent is a company) State Zip (c) If the Financially Responsible Party is engaging in business under an assumed name, give name under which the company is Doing Business As. If the Financially Responsible Party is an individual, General Partnership, or other company not registered and doing business under an assumed name, attach a copy of the Certificate of Assumed Name. Company DBA Name 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(s) 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 Party). I agree to provide corre ted information should theme be any change in the information provided herein. Typ print name Title or Authority 47a,��;� ►- 5L z 2- Signature Date ------------------------------------------------------------------------------------------------------------------------------------ 1, C�1n _, a Notary Public of the County of P_\CN\o�bnd State of North Carolina, hereby certify that aY Od PEWQ'_4 1 _appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/her. 2 Witness my hand and notarial seal, this cJ day of \N Ch , 20 -2— CO,_ ,�� M\_,� AkAj Notary Sell a � My commission expires ,