HomeMy WebLinkAboutNCC230024_FRO Submitted_20230104FINANCIAL 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 NameChaney Concrete Batch Plant
2. Location of land -disturbing activity: Count yCu rrltuck City or Township Powell's Point
104 Hines Commerce Drive 36.1140-75.8312
Highway/Street LatltUde(decimaldegrees) Long ltUde(decimaldegrees)
3. Approximate date land -disturbing activity will commence: 1 /1 /23
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.00 acres
6. Amount of fee enclosed: $300 . 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 ❑x No ❑
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Kyle Murray E-mail Address kmurray@chaneyenterprises.com
Phone: Office # 301-932-5000 Mobile # 443-871-3440
Landowner(s) of Record (attach accompanied page to list additional owners):
Southstar Limited Partnership 443-871-3440
Name Phone: Office # Mobile #
176 Mine Lake Court, Suite 100
Current Mailing Address
Raleigh, NC 27615
City State Zip
Current Street Address
City
State
Zip
10. Deed Book No. 1715 Page No. 1 29-131 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 companyis a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
NC Chaney Enterprises Limited Partnership
Company Name
176 Mine Lake Court, Suite 100
Current Mailing Address
Raleigh, NC 27615
kmurray@chaneyenterprises.com
E-mail Address
2410 Evergreen Road, Suite 201
Current Street Address
Gambrills, MD 21054
City State Zip City State Zip
Phone: Office # 301-932-5335 Mobile # 443-871-3440
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:
Incorp Services, Inc.
Name of Registered Agent
E-mail Address
176 Mine Lake Court, Suite 100
176 Mine Lake Court, Suite 100
Current Mailing Address
Current Street Address
Raleigh, NC 27615
Raleigh, NC 27615
City State Zip
City State Zip
Phone: Office # 800-246-2677
Mobile #
Isabel Burgos
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.
Kyle Murray Land General Manager
Type or prin ame
Sign re
--------------------------------------------------------------
Title or Authority
Date
a Notary Public of the County of Ca I v&4
llAeA,( 1QnA
State of N�feltt-,a, hereby certify that KU) e 01 urY-ct appeared personally
before me this day and being duly sworn acknowl dged that the abwa form was executed by him/her.
Witness my hand and notarial seal, this 3l .5� day of QCiT3bc-(- 20 7
v�
Notary
Seal
My commission expires
p �1311 KE STLV NSM
Nowy RM
1✓alvt'A11 1:WO1111 County, ��