NCC216410_FRO Submitted_20211118

Environmental Qua!ity
v IE413 Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM Q;T 2 7 2021
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the r9W& ffi79
form and an acceptable erosion and sedimentation control plan have been completed Aw0 P-` 06 i(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 Nameef/�/lf�
2. Location of land -disturbing activity: County --[)Ali T r= City or Township
Highway/Street VQ _X R Q_T 1-f-I Latitude Longitude
3. Approximate date land -disturbing activity will commence: b'7y)
4. Purpose of development (residential, commercial, industrial, institutional, etc.): '"RE—SIDTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ to 5 . '` The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $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 MXV E E6-5--> V)q E-mail Address
Telephone Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Current Mailing Address
U�`"IS' \ Jc! �4w1 c: 2 7lJ
City State Zip
,5�3 u ^ 5 � e, 5gC)o
Telephone Fax Number
Current Street Address
City
State
Zip
10. Deed Book No. 13 Page No. Z LI 2-- 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.
C9
i +
L . eyey
Name E-mail Address
Current Mailing Address
City State Zip
?
Telephone ):3 ' - -_5 i0o
Current Street Address
City
Fax Number
State
Zip

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:
Name
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
Name of Registered Agent
Current Mailing Address
CRY State
E-mail Address
Current Street Address
Zip City
Telephone Fax Number
State Zip
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.
Type or print naBIG, Title or Authority
Signature v Date
a Notary Public of the County of / Y
State of North Carolina, hereby certify that Miyy 0;Os w a- rwy i-1;;,gtin,,,j appeared
personally before me this day and being duly swom acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this io�-d - 20
MIRANDA A WATE8WELLMAN otary
Notary Pub is
North Carolina y GOmml ion expires
Forsyth County