HomeMy WebLinkAboutNCC232893_FRO Submitted_20230926 t I'
• FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Lucia Specialized Hauling Office & Warehouse
Camden South Mills
2. Location of land-disturbing activity: County City or Township
Eco Park Blvd 36.5247000 -76.35465833
Highway/Street Latitude{decimal degrees) Longltude(decimaldegrees)
3. Approximate date land-disturbing activity will commence: September 2023
4. Purpose of development(residential,commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 8.00
6. Amount of fee enclosed `P2,800.00 The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed.$2,000.00 (Example:8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
7. Has arr erosion and sediment control plan been filed? Yes❑ Enclosed m No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Hunter Brown hbrown@alexanderdesignbuild.com
Name E-mail Address
Phone: Office# 919-324-9261 Mobile# 919-915-0427
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Lucia Specialized Hauling of Va, Inc 757-558-8700 518-441-555,
Name Phone: Office# Mobile#
1500 Steel Street 1500 Steel Street
Current Mailing Address Current Street Address
Chesapeake VA 23323 Chesapeake VA 23323
City State Zip City State Zip
10. Deed Book No.438 Page No.314 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)maybe listed as the financially responsible party(ies).
Lucia Specialized Hauling of Va, inc luciaspecializedva@g mail.corn
Company Name E-mail Address
1500 Steel Street 1500 Steel Street
Current Mailing Address Current Street Address
Chesapeake VA 23323 Chesapeake VA 23323
City ' State Zip City State Zip
Phone: office# 757-558-8700 Mobile# 518-441-5554
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:
Amy Alston Wells receptionist@gaylordmcnally.com
Name of Registered Agent E-mail Address
498 Red Banks Road 498 Red Banks Road
Current Mailing Address Current Street Address
Greenville NC 27858 Greenville NC 27858
City State Zip City State Zip
Phone: Office#252-321-7111 Mobile#
N/A
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:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A
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.
N/A
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
O'Kane and Associates, PLLC brian@okaneandassociates.com
Engineering firm or other consultant E-mail Address
Brian O'Kane, PE 252-702-1910 252-702-1910
Individual contact person (type or print) Phone: Office# Mobile#
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.
Richard Lucia President
Type or print me Title or Authority
8/29/2023
Signat e Date
I, \ otine Notary Public of the County of L'j p'ap ICM
Vircnni
State of , hereby certify that KidenYd [ADD 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 2v` day of UQS- , 20 23
JENNIFER ILENE BANDY
Notary Public
Commonwealth of Virginia NO ry
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ommission Expires April 30, �
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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:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
N/A N/A
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 3 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
i Landowner 4 of Record:
N/A N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No. N/A Provide a copy of the most current deed.
Landowner 5 of Record:
N/A• N/A N/A
Name Phone: Office# Mobile#
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Deed Book No. N/A Page No N/A Provide a copy of the most current deed.
I
i
Continued from Item 1 in Part B of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A N/A
Company 2 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 3 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 4 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A
N/A N/A
Company 5 Name E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A N/A
City State Zip City State Zip
Phone: Office# N/A Mobile# N/A