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HomeMy WebLinkAboutNCC233566_FRO Submitted_20231204 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 and/or fax information unavailable, place N/A in the blank.) Part A. 1. Project Name: NCNG Reidsville Renovation and Addition 2. Location of land-disturbing activity: County Rockingham City or Township: Wentworth Highway/Street: NC-65 Latitude 36.388701 N Longitude -79.749496 W 3. Approximate date land-disturbing activity will commence August 2021 4. Purpose of development (residential, commercial, industrial, institutional, etc.): Institutional/Military 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 5.61 acres 6. Amount of fee enclosed: $ 1,890.00. The Express Permitting application fee is a dual charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585). 7. Has an erosion and sediment control plan been filed? Yes ✓ No Enclosed ✓ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name LTC Robyn Bryant E-mail Address robyn.s.bryant.mil(a@mail.mil Telephone 919-664-6116 Cell # 828-320-8053 Fax# None 9. Landowner(s)of Record (attach accompanied page to list additional owners): North Carolina National Guard 919-345-6137 None Name Telephone Fax Number 1636 Gold Star Drive, Suite 2600 1636 Gold Star Drive, Suite 2600 Current Mailing Address Current Street Address Raleigh NC 27607 Raleigh NC 27607 City State Zip City State Zip 10. Deed Book No. 772 &709 Page No. 2263 &321 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.) North Carolina National Guard rodney.d.newton.mil(amail.mil Name E-mail Address 1636 Gold Star Drive, Suite 2600 1636 Gold Star Drive, Suite 2600 Current Mailing Address Current Street Address Raleigh NC 27607 Raleigh NC 27607 City State Zip City State Zip Telephone 919-345-6137 Fax Number None 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 (c) In 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: Timmons Group frank.slinskyAtimmons.com Engineering Firm or other consultant E-mail Address Frank Slinsky Ill, PE 919-866-4505 919-859-5663 Individual contact person (type or print) 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. Rodney D. Newton FMO—Facility Management Officers Type or print name Title or Authority /5 Tail 2 0Z/ Signature Date I, '(UY)CLrl-� ./`ACU ► , a Notary Public of the County of \A;60L State of North Carolina, hereby certify that ' Cluk ,`-k ( -& lE_ Qt 1 appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him. Witness my hand illf wtarial seal, this ��-) day of 1fl O « L.\ , 20 0l l `‘`‘,`P`NT H,q i�1O i'G P 9 /� No --Notary Public ' % Sea lwake County = y commission expires 15 Doc 29 My Comm. Exp. Inc Ci'-I 09 'i C A1k0 ��`��