NCC230311_FRO Submitted_20230228

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: Town of Wadesboro Pump Station Replacements and Force Main Improvements
2. Location of land -disturbing activity: County: Anson City or Township: Town of Wadesboro
Highway/Street: Various — See Plans Latitude: 34.9464 Longitude:-80.0750
3. Approximate date land -disturbing activity will commence: April 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): General - All
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.00 acres
6. Amount of fee enclosed: $455. 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: David Edwards E-mail Address: [e-mail]
Telephone: [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Wadesboro 704-694-5171
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.
Town of Wadesboro
Name
PO Box 697
Current Mailing Address
Wadesboro NC 28170
City State Zip
[e-mail]
E-mail Address
124 East Wade Street
Current Street Address
Wadesboro NC 28170
City State Zip
Telephone: [phone] Fax Numbe

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:
Not Applicable
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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:
Not Applicable
Name of Registered Agent
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number.....
State Zip
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.
David Edwards Town Manager
Type or print name Title or Authority
17,118 /
Signature Date
c. 5 , a Notary Public of the County of �VA N%
State of North Carolina, hereby certify that a, appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him.
Witness my hand and notarial seal,
0%J11rJ'' L
P� ES '
o Pam' '
o'
Seams gee�
N
PUS •�
'•J
ON1111111
this ` %day of C'. R . 20 _
Notary My COMMISSIon Expires May 21, 2022
My commission expires