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HomeMy WebLinkAboutNCC231674_FRO Submitted_20230608 Check if this project is ARPA-funded ❑ 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, including any activity under a common plan of development of this size as covered by the NCGO1 permit, 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 NameHelen Nichols Park New Walking Trail *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). Forsyth Winston-Salem 2. Location of land-disturbing activity: County City or Township Carver School Rd. 36.13 80.21 Highway/Street Latltude(decimal degrees) Longitude(decimal degrees) 3. Approximate date land-disturbing activity will commence: July 20, 2023 Public Park Renovation 4. Purpose of development(residential, commercial, industrial, institutional, etc.): 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): +/- 20,000 sf 6. Amount of fee enclosed: $100.00 . 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 Ms. Renata Owens E-mail Addressrenatao@Cityofws.org Phone: Office# 336-734-1222 Mobile# 336-416-5309 9. Landowner(s) of Record (attach accompanied page to list additional owners): City of Winston-Salem 336-734-1222 336-416-5309 Name Phone: Office# Mobile# P.O. Box 2511 100 E. First Street, Suite 407 Current Mailing Address Current Street Address Winston-Salem, NC 27102 Winston-Salem, NC 27101 City State Zip City State Zip 10. Deed Book No.001480 Page No.01 370 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 party(ies). City of Winston-Salem renatao©cityofws.org Company Name E-mail Address P.O. Box 2511 100 E. First Street- Suite 407 Current Mailing Address Current Street Address Winston-Salem, NC 27101 Winston-Salem, NC 27105 City State Zip City State Zip Phone: Office# 336-734-1222 Mobile# 336-416-5309 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. TypYPencL� �Vean 5 5s-I . --arks I) rec�v r or print name Title or Authority Aha-A-4-1 Nazi I/ 21)23 Sign ture Date • 1OY-4-01A , a Notary Public of the County of Grr State of North Carolina, hereby certify that ka4-PIL U\ J AA-S 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 , 20 DIAUNAYHORTON No ary NOTARY PUBLIC Y COUNTY OF FORSYTH �7 STATE OF NORTH CARO NA My commission expires I ‘ l3 MY COMMISSION EXPIRES i '