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HomeMy WebLinkAboutNCC230151_FRO Submitted_20230125FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT EXPRESS PERMITTING OPTION 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 Cummins Warehouse Laydown Area 2. Location of land -disturbing activity: County Nash City or Township Whitakers US 301 36.091584-77.728605 Highway/Street Latltude(decimal degrees) _ LOngltude(decimal degrees) 3. Approximate date land -disturbing activity will commence: November 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.9 acres 6. Amount of fee enclosed $ 500+$1250 The Express Permitting application fee is a dual charge. The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name Nick Kraft E-mail Address NKraft@laytonconstruction.com Phone: Office # Mobile # 615-390-6857 9. Landowner(s) of Record (attach accompanied page to list additional owners): Consolidated Diesel, Inc. 252-985-8459 Name Phone: Office # Mobile # 9377 N US Highway 301 9377 N US Highway 301 Current Mailing Address Current Street Address Whitakers NC 27891 Whitakers NC 27891 City State 10. Deed Book No. 1082 Zip City Page No. 51 State Zip Provide a copy of the most current deed. Part B. i. 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). Consolidated Diesel, Inc. Company Name 9377 N US Highway 301 Current Mailing Address Whitakers NC 27891 City State Zip Phone: Office # mark.tufts@cummins.com E-mail Address 9377 N US Highway 301 Current Street Address Whitakers NC 27891 City State Mobile # 252-985-8459 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 Current Mailing Address City State Zip Phone: Office # E-mail Address Current Street Address City State Zip 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 otter company not registered and doing business under an assurned name, attach a copy of the Certificate of Assumed Name, Company DBA Name (d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other consultant who can assist in providing any necessary information regarding the plan and its preparation: Appian Consulting Engineers, PA Engineering firm or other consultant David Revoir Individual contact person (type or print) drevoir@appianengineers.com E-mail Address 252-972-7703 Phone: Office # Mobile # 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. Steven Pinkston Plant Manager Type or pr' n m Title or Authority 3 Signature ®ate 1, A'Z41,'111 /" Lr/f��.�i'S%� , a Notary Public of the County of State of North Carolina, hereby certify that 101AIA.5'r°.1 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 /_day of `�- V , 20 a 3 FLAINE F. CEGLARSK' � � ����✓ mOv►Ar pL*Llr "SH COUNTY, r" i_. Notary Seal My commission expires / ' a°'t 5r Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed, Landowner 4 of Record: Name Current Mailing Address City State Deed Book No. Landowner 5 of Record: Phone: Office # Current Street Address Zip City Page No. Mobile # State Zip Provide a copy of the most current deed. Name Phone: Office # Mobile # Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item 9 in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Phone: Office # Mobile # Company 3 Name Current Mailing Address City State Phone: Office # E-mail Address Current Street Address Zip City State Mobile # Zip Zip t.:urr'i_................ _... ...... ........... ..-.....,....___...-. pa�'iy 4 IVdrrre E� -rr'idil Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # Mobile # Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # __ Mobile #