NCC222960_FRO Submitted_20220823

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 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 NIA in the blank.)
Part A. Norwood Waste Pit
1. Project Name
2. Location of land -disturbing activity: County Stanly City or Township Norwood
Highway/Street US Highway 52 S Latitude 350 12' 37.75" Longitude-800 38' 22.66"
3. Approximate date land -disturbing activity will commence: May, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.06
6. Amount of fee enclosed: $ 400.00 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Kevin Thomas E-mail Address [e-mail]
Telephone [phone] Cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to fist additional owners):
A & E Property Management LLC 704-920-2100
Name Telephone
8325 US Highway 52 South
Current Mailing Address
Norwood NC
City
State
Current Street Address
28128
Zip City
Fax Number
State Zip
10. Deed Book No. 1740 Page No. 90 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.
Lynn Thomas Grading, Inc. [e-mail]
Name
230 Rocky River Church Road
Current Mailing Address
Polkton NC 28135
City State
Telephone [phone]
E-mail Address
Current Street Address
Zip City State Zip
Fax Number

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 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:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City
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.
Frances Turner Thomas
Type or print name
President
Title or Authority
Signature Date
I, 311 f,12Ln ti , a Notary Public of the County of hc��.
State of North Carolina, hereby certify that r-y-ai'il"cs-VtAwyr � +fYl� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this I1 )day of Ma,t 1 , 20
,,& &rxan, .
Notary
Seal
My commission expires

3/21/22
NCDEQ— Mooresville Regional Office
610 East Center Ave.
Mooresville, NC 28115
To Whom It May Concern:
This letter is to inform you that Lynn Thomas Grading, Inc. will be performing site grading on the below
referenced property for use as a waste pit. Lynn Thomas Grading, Inc. will be responsible for installing
and maintaining all erosion control devices pertinent to this project.
REFERENCED PROPERTY:
Property Identification Number: 656304734732
Town of Norwood
Stanly County, NC
Location: 8325 US Highway 52 South
Norwood, NC 28128
Thank You,
Christopher Campbell, Managing Member
A & E Property Management, LLC )