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HomeMy WebLinkAboutNCC223342_FRO Submitted_20220927FINANCIAL 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. TEAB - Hammocks Beach State Park 1. Project Name 2. Location of land -disturbing activity: County Onslow City or Township Swansboro Highway/Street Hammocks Beach Rd Latitude 340 40' 24.02" N Longitude 770 8' 24.37" W 3. Approximate date land -disturbing activity will commence: November 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.0 6. Amount of fee enclosed: $ 260 . 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 Jerry Howerton E-mail Address jerry.howerton@ncparks.gov Telephone (919) 707-9361 Cell # Fax # 9. Landowner(s) of Record (attach accompanied page to list additional owners): State of NC Name Telephone Fax Number P.O. Box 629 Current Mailing Address Current Street Address Raleigh NC 27602 City State Zip City State Zip 10. Deed Book No. 903 Page No. 430 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. NC Division of Parks and Rec. jerry.howerton@ncparks.gov Name E-mail Address 1615 Mail Service Center Current Mailing Address Raleigh, NC 27699 City Current Street Address State Zip City Telephone (919) 707-9361 Fax Number State 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 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. Jerry Howerton Chief of Design and Construction Type or print name Title or Authority L�A� 3 - 91 C> gnat Date ------------------------------------------------------------------------------------------------------------------------------------ I, T Jai �� YLb a Notary Public of the County of VV _?­� State of North Carolina, hereby certify that ✓N �6wub7'� appeared personally before me this day and being duly rn acknowledged that the above form was executed by him. Witness my hand and notarial seal, this 3+_1 ,rt day of 1 ` O-" . , 20 2-4 e(� t dl (� Notary eal Heide Rumble NOTARY PUBLIC My commission expires WAKE COUNTY, N.C.