NCC232190_FRO Submitted_20230804

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. Providence Boulevard Road Improvements - Phase 3
1. Project Name
2. Location of land-disturbing activity: County Johnston City or Township Selma
Highway/Street US 70-70A1SR23741SR2305 Latitude 35.5187 Longitude-78.2856
3. Approximate date land-disturbing activity will commence:4/4/22
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Roadway
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):46.0
$500-41 ac disturbed area previously paid i @ 1 00
6. Amount of fee enclosed: $ . The application fee of,W per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $goo)
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 Kevin Dougherty E-mail Address [e-mail]
Telephone [phone] Cell# 412-302-2415 Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Eastield Associates, LLC 919-965-5661 919-965-8568
Name Telephone Fax Number
101 S. Raiford St, suite 200 101 S. Raiford St, suite 200
Current Mailing Address Current Street Address
Selma, NC 27576 Selma, NC 27576
City State Zip City State Zip
10. Deed Book No.See separate page 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.
Eastfield Associates, LLC [e-mail]
Name E-mail Address
101 S. Raiford St, suite 200 101 S. Raiford St, suite 200
Current Mailing Address Current Street Address
Selma, NC 27576 Selma, NC 27576
City State Zip City State Zip
Telephone [phone] Fax Number 919-965-8568

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:
N/A
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:
N/A
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.
Kevin M. Dougherty Manager
Type or�print name - Title or Authority
Signature - _Date
_�__..- .._______________ ' .� --..--_-r_---- ----------------_ _..-----
_____--_-----------_____ _----
I, 106 pt aun _ , a Notary Public of the County of
State of North Carolina, hereby certify that appeared
personally before me this day and being my sworn 'aci7nXle' dged'V that the above form was
executed by him.
Witness my hand and notarial seal, this day of M0,61,
120 r
��:�o °�•• 'L�'s Notary
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My commission expires13LVO C.)
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EASTFFELD ASSOCIATES;, LLC KS Bank 10832
101 South Raflbrd S€feet,Suite 200 Selma. NC
Selma, NC 27576
919-965-5661 2531707158
**** FIVE HUNDRED AND 00/100 DOLLARS:
TO THE 03/28/2023 $500 . 00*****
ORDER OF
NC Department of Environmental Quality `1
II' i08 3 2w, 1: 2 5 3 00 7 SEW 0"000 28 9 6 to L,V
DATE:03/28/2023 CK#:10832 TOTAL:$500.00***** BANK:KS Checking Eastfield Assoc. (ksckef)
PAYEE:NC Department of Environmental Quality(ncenv)
Property Address -Code Invoice- Date Description Amount
Eastfield Associates, LLC - eastf Prov Road Improvements; additional acreage 500.00
500.00