NCC230256_FRO Submitted_20230130

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: Alamance County MSWLF Landfill
2. Location of land -disturbing activity: County: Alamance City or Township: Graham
Highway/Street 2701 Austin Quarter Road Latitude 35d56'25" Longitude-79d13'34"
3. Approximate date land -disturbing activity will commence: November 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Next Phase of Landfill
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 37 acres
6. Amount of fee enclosed: $ 2,405.00 . 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: Richard Hill E-mail Address: Richard. Hill@Alamance-nc gov
Telephone [phone] Cell #
Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Alamance County 336-228-1312
124 W. Elm Street
Current Mailing Address
Graham NC 27253
City State Zip
124 W. Elm Street
Current Street Address
Graham NC 27253
City State Zip
10. Deed Book No. 778 Page No. 496 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.
Alamance County
Name
124 W. Elm Street
Current Mailing Address
Graham NC 27253
City State Zip
336-228-1312
Telephone
124 W. Elm Street
Current Street Address
Fax Number
Graham NC 27253
City State Zip
Telephone [phone] Fax Numb

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.
Bryan Haygood County Manager
Type or print name Title or Authority
Signature 0Date
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I, TDry 11 FYI n , a Notary Public of the County of larnewc
State of North Carolina, hereby certify that _�'appeared
o acknowled d that
personally before me this day and being duly swthe above form was
executed by him.
Witness my hand and notarial seal, this LUay of�?&_,"Ler , 20,2.�_
TORY MCCORKLE FRINK
Notary Public, North Carolina Notary
Alam$�ggLFounty
My Commission Expires
March 21, 2024 My commission expires r