NCC230039_FRO Submitted_20230106

Check if this project is ARPA-funded ❑
FINANCIAL RESPONSIBILITYIOWNERSHIP 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.G. 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 NIA in the blank.)
Part A.
Project Name A A S� ffd //Q—
*If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below
Under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County Dv %i,i City or Township "l/AC
Highway/Street Latitude(decimat degrees) -it, 7VI Longitude(decimai degrees) - 7
3_ Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.)_ �d�►htrcr.(
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):,
6. Amount of fee enclosed: $ Zed _ 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 3/Enclosed ❑ No ❑
8_ Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name e,4 �/`?S¢�� E-mail Address `,04f6oh
Phone: Office #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
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Nam69
1/0) 26z-2rf/
Phone: Office # Mobile #
0113 13-- f"k IJ r SA_ /'I e—
Current Mailing Address Current Street Address
wT A-, nilvx /1/G Algl(
City U State Zip
City
State
Mobile #
Zip
10. Deed Book No_ /6.5e Page No. W 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 owners) may be listed as the financially responsible party#es).
e 0 4 e I !% e j
Co any Name
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Current Mailing Address
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city j State Zip
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E-mail Address
S& h e
Current Street Address
city
Phone: Offce # (11 «) 2 6 Z ` Zf 3 F Mobile #
State
Zip
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:
44--t 49 �-en UA,S
NamEfof Registered Agent
g Lr3 g6jWi P ., ..De ._
Current Mailing Address
t,li 6/1 Al (- a_ �(f0
City State Zip
5 (/�''S�-ru. c 0 Or-e G i S i al C of L,-I&S 4 4 a 194;d4 cGy'►
E-mail Address
57^--0-q R__
Current Street Address
City
Phone. Office # t 1 to 1 2 C 2- ZV.31 Mobile #
State Zip
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.
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_
T� hZn UM��2�t
Type dr print name
Sign ture
6 L')� �_)-
Title or Authority
Date
1Z // 712 2-
a Notary Public of the County of oye
State of North Carolina, hereby certify that 1 Uffi_(*44 appeared personally
before me this day and being duly sworn ackkjno, edged that the above form was executed by hint/her.
Witness my hand and notarial seal, this � l day of � !� , 20
�)A tY ti
otary
Deborah Jones
Notary Public My commission expires
New Hanover County, NC
My Commission Expires 12/0212026