NCC223814_FRO Submitted_20221115

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 address or phone number is unavailable,
place N/A in the blank.)
Part A.
1.
2.
3.
4.
5.
6.
7.
8.
ti
Project Name: _Ashe Co. Municipal Solid Waste Landfill Facility -Revision to Approved Plan
Location of land -disturbing activity: Count: _Ashe City or Township: _Jefferson
Highway/Street: _S.R. 1558_ Latltude(decimaidegrees)_36.51944_ Long itude(decimaidegrees)_81.36833
Approximate date land -disturbing activity will commence: _ASAP
Purpose of development (residential, commercial, industrial, institutional, etc.):_Borrow Sites
Total acreage disturbed or uncovered (including off -site borrow and waste areas):_12.3 acres of Re -
Disturbed in Borrow Site #1 and Additional 10 acres of Borrow Area #2) = 23 Acres
Amount of fee enclosed: $_2300.00 . 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.
Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑ No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name: _Scott Hurley
Phone: Office # 336.846.3721
E-mail Address scott.hurleycD-ashecountVgov.com
Mobile #
Landowner(s) of Record (attach accompanied page to list additional owners):
_County of Ashe
Name
_ 150 Government Circle Suite 2500
Current Mailing Address
_ Jefferson, NC 28640
City State
336.846.5501 _
Phone: Office # Mobile #
Same
Current Street Address
Same
Zip City
State
Zip
10. Deed Book No._374 Page No._2250 Provide a copy of the most current deed.
175 1594

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).
_Adam Stumb, County Manager
Company Name
_150 Government Circle Suite 2500
Current Mailing Address
_Jefferson NC 28640
City State Zip
Phone: Office # 336.846.5501
[e-mail]
E-mail Address
same
Current Street Address
same
City
Mobile #
State
Zip
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 activity.
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City State Zip
Phone: Office #
Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(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 corrected
information should there be any change in the information provided herein.
Adam Stumb
Type or pri �
;F�
ignature
_County Manager.
Title or Authority
%ZS /Z 0 �-Z
Date
I,�10_-rbOa TRUOOc� V1 , a Notary Public of the County of Sin 2
State of North Carolina, hereby certify that AAa\'v\ 5iqAM\' appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this D? 3 ay of Sea�LmloU , 20 A i�
M� Comraq. Exp, j
Notary
s;�°�'
My commission expires