NCC230355_FRO Submitted_20230208

FINANCIAL RESPONSIBILITY/OWNERSHIP rORM
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 Columbus County Water & Sewer District IV Water System Improvements - EDA
2. Location of land -disturbing activity: County Columbus City or Township Ransom (Delco)
Highway/Street US Hwy 74/76, NC Hwy 11 Latltude(decimal degrees) 34.3172 Longltude(decimal degrees) - 78 2802
3. Approximate date land -disturbing activity will commence: March 1, 2023
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Municipal Water Supply
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.25
6. Amount of fee enclosed: $ 800.00 . 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 W. Landon Younce, PE E-mail Address [e-mail]
Phone: Office # [phone] Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Columbus County [phone]
Name Phone: Office # Mobile #
127 W. Webster Street 127 W. Webster Street
Current Mailing Address
Whiteville, N.0
Current Street Address
28472 Whiteville, N.C. 28472
City State Zip City
10. Deed Book No. RB 1216 page No. 366 - 372
State
Zip
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 parly(ies).
Columbus County
Company Name
127 W. Webster Street
Current Mailing Address
Whiteville, N.C. 28472
City State Zip
Phone: Office # [phone]
[e-mail]
E-mail Address
127 W. Webster Street
Current Street Address
Whiteville, N.C. 28472
City State Zip
Mobile #
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 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:
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.
Edwin H. Madden, Jr. County Manager
Type or print name Title or Authority
oa�
Signature Date
Q ack v ro a Notary Public of the County of LI 5
State of North Carolina, hereby certify that GAWir) R. Maddey 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
NATALIE CARROLL Notary
of ry public
CO us County My commission expires
North Carolina

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
Phone: Office #
Current Street Address
City State Zip City
Deed Book No. Page No.
anrlrnninar ri of Rarnrrl-
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
Deed Book No. Page No.
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 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
Current Mailing Address
City
Phone: Office #
Company 3 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip
E-mail Address
Current Street Address
State Zip City State Zip
Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
City
Phone: Office #
E-mail Address
Current Street Address
State Zip City State
Mobile #
Zip
IN