HomeMy WebLinkAboutNCC233333_FRO Submitted_20231108 Check if this project is ARPA-funded ❑
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 NCGO1
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. Name �h�`�I S VQ,I,i 1" 1N141i CPA bc VoN.00�1� t
*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 f landisturbing activity: County iAStOut, City or
Township S1'1,ILS
Highwa /Stye t t v 1. Latitude(decimal degreesS 3 U. Long itud e(decimal
degrees) �y
3. Appr_gximaiye date
to land - disturbing activity will
commence: b jt v
4. Purpose of 4evelopment (residential, commercial, industrial, institutional,
etc.):C,>y y 9(C M
5. Total a reage disturbed or uncovered (including off-site borrow and waste
areas): .�
6. Amount of fee enclosed: $ 10% •00 . 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"
Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing
activity:
N m g 1 o1N�l/(V E - m a i I
AddresscloW OJ' . GNP
Phone : Office # Mobile #
NO si a---r31 ,
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Va,eN (CliC‘) C‘i.1 CalS
Name 1`�rs Phone: Office# Mobile#
a $7
Current Mailing Address Current Street Address
City State Zip City State
Zip
10. Deed Book No. {V4 Page No. 143 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).
)elm I t ,6 f���.�_5-�-@ (Abi- „I
Company Name E-mail Address
2 l7 be, u 3 c . 2, 17 pc- 0(s S.-h.
Current Mailing Address Current Street Address
Si r,,, ?Ales BUG 2i 3S1 7_5?"3?7
City State Zip City State Zip
Phone: Office# /Vit. Mobile# (1)9) � - G 2 /5
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:
• e (clue-,-. v �4-)ConcorDa rG 0.4e.
Name of Registered Agent E-mail Address
17'(
Current Mailing Address Current Street Address
(rtt7 Nz- 2737( 5
City State Zip City State Zip
Phone: Office# Af A- Mobile# 0/o) 72, ?3 t C.
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)
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.
i. . e W- I cL ' ow.
l.41511.1 Jire..AL 1 k u.11'
Type or print name Title or Authority
Cyr
Signature Date t 6/014/421023
I, , a Notary Public of the County of
rAINAfrentivl-
State of North Carolina , hereby certify that
'pQNt'd W , .(,r t.4A— appeared personally before me this day and being
duly sworn ar viledged that the above form was executed by him/her.
.•`��LpA ALQil��i
WitnesiVnand a �L arial seal, this o2.to day of OC -94 U. , 20 a 3
.` P ,,QTq,9 Z S.
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c.)2 °UBL�G 2; tary
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