HomeMy WebLinkAboutNCC230105_FRO Submitted_20230113FINANCIAL 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 Statesville Fire Station No. 1 Soil Borrow Site
2. Location of land -disturbing activity: County Iredell City or Township Statesville
Wilson W. Lee Blvd. 35.7607561-80.8859407
Highway/Street Latltude(decimal degrees) LOngltUde(decimal degrees)
3. Approximate date land -disturbing activity will commence: November, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Public Service
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5
6. Amount of fee enclosed: $ 200.00 . 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.
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 Mike Carllsto E-mail Address mcarllsto@edlficelnc.Com
Phone: Office # 704-332-0900 Mobile # 704-3095613
9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Statesville 704-878-3550
Name
PO Box 1111
Current Mailing Address
Phone: Office # Mobile #
227 South Center Street
Current Street Address
Statesville, North Carolina 28687 Statesville, North Carolina 28687
City State Zip City State Zip
10. Deed Book No. 2342 Page No. 758 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).
City of Statesville
Company Name
PO Box 1111
Current Mailing Address
Statesville, North Carolina 28687
City State Zip
Phone: office # 704-878-3550
E-mail Address
227 South Center Street
Current Street Address
Statesville, North Carolina 28687
City State
Mobile #
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:
N/A
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:
N/A
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.
N/A
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.
Mark Taylor
Public Works Director
Type or print name Title or Authority
-7 is Ala,/ 2ott
Si ature Date
a Notary Public of the County of :L Ltl�
State of North Carolina, hereby certify that Y�.ayNappeared 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 __W*12y of rJ �Y e.r�,peY 20 a
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Notary
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VENDOR: 12661 NC DEQ
9320
10/21/2022
DATE INVOICE #
9/26/2022 147945
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PO # DESCRIPTION
SEDIMENTATION/POLLUTION FIRE STATION 1
TOTAL
DEPOSIT DATE
1 1
PAY *** VOID *** NON-NEGOTIABLE *** VOID *** FOR INFORMATION ONLY *** VOID ***
TO THE NC DEQ
ORDER 1633 MAIL SERVICE CENTER
OF RALEIGH, NC 27699-1633
AMOUNT
200.00
200.00
Check #: 9320
FIRST CITIZENS BANK
200.00
EFT Payment Summary