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HomeMy WebLinkAboutNCC232388_FRO Submitted_20230811 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 Name Dollar General - Nashville *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). 2. Location of land-disturbing activity: County Nash City or Township Nashville Oak Level Rd&E Old Spring Hope Rd 35.9584 -77.9281 Highway/Street Latitude(decimal degrees) Long itude(decimal degrees) 3. Approximate date land-disturbing activity will commence: August 1 , 2023 4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.3 6. Amount of fee enclosed: $300.00 . 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 0 Enclosed 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name George T. Barnes E-mail Addressgbarnes@vanguardpg.com Phone: Office# 919.459.2601 Mobile# 919.542.2020 9. Landowner(s)of Record (attach accompanied page to list additional owners): Ronnie Phil Burnette Name Phone: Office# Mobile# 2258 Oak Level Road 2258 Oak Level Road Current Mailing Address Current Street Address Rocky Mount, NC 27804 Rocky Mount, NC 27804 City State Zip City State Zip 10. Deed Book No.528 Page No.339 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). Glandon Forest Equity, LLC gbarnes@vanguardpg.com Company Name E-mail Address 3825 Barrett Drive, Suite 100 3825 Barrett Drive, Suite 100 Current Mailing Address Current Street Address Raleigh, NC 27906-7221 Raleigh, NC 27906-7221 City State Zip City State Zip Phone: Office# 919.459.2601 Mobile# 919.459.2602 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: George T. Barnes, Jr. gbarnes@vanguardpg.com Name of Registered Agent E-mail Address 3825 Barrett Drive, Suite 100 3825 Barrett Drive, Suite 100 Current Mailing Address Current Street Address Raleigh, NC 27906-7221 Raleigh, NC 27906-7221 City State Zip City State Zip Phone: Office# 919.459.2601 Mobile# 919-459.2602 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. George T. Barnes, Jr. Registered Agent Type or print A1)n Title or A thorty ? I 2,3 Signature Date 6L)n lvt(.33(1, �pJr.� , a Notary Public of the County of State of North Carolina, hereby certify that �t.i0v Cal.. 1730,r r\.5-5 appeared personally before me this day and being duly sworn acknowledge)1 that the above form was executed by him/her. Witness my hand and notarial seal, this 1 X day of 1 ' '°-M , 20 `ta111t�))sU:r�flgrri. al IAA 41i,CALL � •,, Notary Sq• r�fl\ 8Y Is = IF cs _ Mycommission expires G "OS " Gso ` ti 4. co°FU,\- � 23 �.