NCC222917_FRO Submitted_20220823

a
FINANCIAL RESP.ONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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 Computed and approved by the —
Land Quality Section, N.C. Department of Environment and Natural Resources. (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 GUiEP?R1�N'><' PF�rlhtC c•, �Qp�p
2. Location of land -disturbing activity: County. 500rlj NGHA1► City or Township fwr- 1N
4t1MNA61ATSPe iW01i V�OA.p
Highway1Street 5 . F% . WZ*} Latitude 3 "7 7 7 d Longitude — 7V • t & °
3. Approximate date land -disturbing activity will commence: 25 -
4. 'Purpose of development (residential, commercial; indusirial,'insUtutional, etc.): IN511N7161, A
5. Total acreage disturbed or uncovered (including ofl`4te borrow and waste areas): 3. 0 A S. Amount of fee enclosed: $ 360 . 0D IVV14a
unded
up to the next acre) is assessed without a calling amount e(Exampi : a tion 9 acre e of app� lion fee er acre
SAW
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control Issues arise during land -disturbing activity:
Name ELcIvl0N5„, .M6F). E-m$flAddress dAt7r4VerWaterinc.&. GmbYr�sti,ai�.c
Telephone Cell# 33&- 432 7722 1=ax# 331-142)b
9. Landowner(s) of Record (attach accompanied page to list additlanal owners):
_-_Art.. wPF7k wr['Hl:s� rAXJ? a,T F7/W
Name d Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
O. 'Deed Boole No. Page No. Provide a copy of the most current deed.
Part S.
1. Person(s) or firm(s) who are financially `responsible for the land-dfsturbfng activity (Provide a
.comprehensive list of all responsible parties an an attached sheet):
PAN t�IVET-7
Name E-mail Address
& 1 D E'ATF7166 5T1%L j'
Current Mailing Address 'Current Street Address
tq. G . Z7288
City State Zip City State Zip
Telephone Faye Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, giye name and stree
of the designated North Carolina Agent t address
Name
Current Mailing Address
city State Zip
Telephone
E-mail Address
Current Sheet Address,
Crty State
Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging assumed name, attach $ Copyin business under an
of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Ca7o'C
Name of Registered Agent
!olc7 ,P `�'PSIGK 57F79ET
Current Mailing Address
am N.C. 2?25�3
city slate Zip
Telephone 33�o-ro23-2�2ia
danriv�rwe:rihe r tnail.tetrt
E-mail Address
Current Street Address
State Zip
Fax Number 33& -CP2-3�- 14D23
The above information is true and correct to the blest 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). 1 agree to provide
corrected information should there be any change in the irtforrmation.provided herein.
NA l YIE LEMONS
TY;T8 or Print name
'! I
Signature
NAGS
Titre or Authority
—'5 - ; ,Z_
Date -
, a Notary Public of the County of
State of North Carolina, hereby certify that—baLki,
Personally before me this day and being duly swam acknowledged that the above form wa
ed
executed by him.
Witness my hand and notarial seal, this __! day of �� 1.119
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