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HomeMy WebLinkAboutNCC240323_FRO Submitted_20240209 Check if this project is ARPA-funded 0 Attach a copy of the Letter of Intent to Fund 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 NCG01 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 PPG High Point Latex Rail Spur *If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure(DWI). 2. Location of land-disturbing activity: County City or Township High Point Highway/Street 201 Old Thomasville Rd Latltudeoecima degrees)assssioaisosiLa1gltude(decimai degrees) -800290115269821 3. Approximate date land-disturbing activity will commence:11/1/2023 4. Purpose of development(residential,commercial, industrial, institutional,etc.):Industrial 5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):3.17 6. Amount of fee enclosed: $400 . 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 ❑ No 0 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Zack Hixon E-mail Address zhixon@ppg.com Phone: Office# Mobile# 336-880-5297 9. Landowner(s)of Record (attach accompanied page to list additional owners): Ennis Paint Inc 1-800-331-8118 Name Phone: Office# Mobile# 4161 Piedmont Pkwy Suite 370 i161 Piedmont Pkwy Suite 370 Current Mailing Address Current Street Address Greensboro NC 27410 Greensbor NC City State Zip City State Zip 10. Deed Book No.7595 Page No. 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). Ennis Flint Inc dba PPG Traffic Solutions rkrahn@ppg.com Company Name E-mail Address 4161 Piedmont Pkwy Suite 370 4161 Piedmont Pkwy Suite 370 Current Mailing Address Current Street Address Greensboro NC 27410 Greensboro NC 27410 City State Zip City State Zip Phone: Office# 1-800-331-8118 Mobile# 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: Randy Krahn rkrahn@ppg.com Name of Registered Agent E-mail Address 201 Old Thomasville Rd 201 Old Thomasville Rd Current Mailing Address Current Street Address High Point NC 27260 High Point NC 27410 City State Zip City State Zip Phone: Office# 1-800-331-8118 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. PPG Traffic Solutions 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. te 114‘'( C)'• 1ct�llV) r'1 /`!cttc3c}c✓ Type or print name Title or Authority I/ac/ay Signature Date I, JeSS i('c1 ICJ C-)Y irl , a Notary Public of the County of C-1(,( 1 Y�t 6 State of North Carolina, hereby certify that V t t► iC/-I 1L-YC 2 Jin appeared personally before me this day and being duly sworn acknowledged(hat the above form was executedI� by him/her. Witness my hand and notarial seal, this 9(t`day of ,\OInGI lYtf , 20 ()C A) I ' ,t# JESSICA D. GRIFFIN N stary Lr N$ttgd Public /1� . 3 �/'�.-js D.--7 Davidson Co.,North Carolina My commission expires l. , My Commission Expires Oct.23,2027 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: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. 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. Company 2 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 4 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 5 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile#