NCC230209_FRO Submitted_20230125

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 and/or fax information
unavailable, place N/A in the blank.)
Part A.
1. Project Name 210 Wastewater Treatment Facility Effluent Force Main
2. Location of land -disturbing activity: County Johnston City or Township_ Smithfield
Highway/Street See attachments Latitude 35.50795 Longitude-78.42594
3. Approximate date land -disturbing activity will commence: April 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Utility
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 20.65 ac
6. Amount of fee enclosed: $ 1,365 . 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 Chandra Farmer E-mail Address [e-mail]
Telephone [phone] Cell # 919-795-4271 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
NCDOT Street Right of Way and Johnston County Owned Easements
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. Page No. 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.
Johnston County [e-mail]
Name E-mail Address
P.O. Box 2263 309 East Market Street
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield _ _NC 27577
City State Zip City State Zip

Telephone
919-989-5100
Fax Number 919-934-7174
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.
Rick J. Hester
Type or print name
Signature
County Man
Title or Ae_
Date
L
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H0�
a Notary Public of the County of )_AnA6V1
State of North Carolina, hereby certify that R ,cQ, , . I�eS�'2.r appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my handw�d 1'Val, this
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` day of rwar 20 �\
Notary
My commission expires 110- �-i �0 a\