20221103_LLC_Annual_Report-DAR

41, LIMITED LIABILITY COMPANY ANNUAL REPORT
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NAME OF LIMITED LIABILITY COMPANY: Smith's Demolition & Clean Up, LLC
SECRETARY OF STATE ID NUMBER: 0803250 STATE OF FORMATION: NC
REPORT FOR THE CALENDAR YEAR: 2021
SECTION A: REGISTERED AGENT'S INFORMATION
1. NAME OF REGISTERED AGENT: Smith, Alvin R. , Jr.
2. SIGNATURE OF THE NEW REGISTERED AGENT:
E - Filed Annual Report
0803250
CA202209404174
4/4/2022 12:30
Changes
SIGNATURE CONSTITUTES CONSENT TO THE APPOINTMENT
3. REGISTERED AGENT OFFICE STREET ADDRESS S COUNTY 4. REGISTERED AGENT OFFICE MAILING ADDRESS
500 Jones Town Rd
Columbia, NC 27925-9769 Tyrrell County
SECTION B: PRINCIPAL OFFICE INFORMATION
500 Jones Town Rd
Columbia, NC 27925-9769
1. DESCRIPTION OF NATURE OF BUSINESS: Debris Removal
2. PRINCIPAL OFFICE PHONE NUMBER: [phone] 3. PRINCIPAL OFFICE EMAIL: Privacy Redaction
4. PRINCIPAL OFFICE STREET ADDRESS
500 Jones Town Rd
Columbia, NC 27925-9769
5. PRINCIPAL OFFICE MAILING ADDRESS
500 Jones Town Rd
Columbia, NC 27925-9769
6. Select one of the following if applicable. (Optional see Instructions)
❑ The company is a veteran -owned small business
❑ The company is a service -disabled veteran -owned small business
SECTION C: COMPANY OFFICIALS (Enter additional company officials in Section E.)
NAME: Alvin Smith , Jr.
TITLE: Manager
ADDRESS:
500 Jonestown Road
Columbia, NC 27925
NAME:
TITLE:
ADDRESS:
NAME:
TITLE:
ADDRESS:
SECTION D: CERTIFICATION OF ANNUAL REPORT. Section D must be completed in its entirety by a person/business entity.
Alvin Smith Jr.
SIGNATURE
Form must be signed by a Company Official fisted under Section C of This form.
Alvin Smith Jr.
4/4/2022
Manager
DATE
Print or Type Name of Company Official Print or Type Title of Company Official
This Annual Report has been filed electronically.
MAIL TO: Secretary of State. Business Registration Division, Post Office Box 29525, Raleigh, NC 27626-0525

Duly Authorized Representative (DAR) Delegation Form
Facility Name: Buddy Smith Mine AI#:
Prior to completing this form, please ensure the person completing this form is an authorized signatory. An authorized signatory is as
follows:
(1) For a corporation. By a responsible corporate officer. For the purpose of this section, a responsible corporate officer means:
(i) A president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any
other person who performs similar policy- or decision -making functions for the corporation, or
(ii) the manager of one or more manufacturing, production, or operating facilities, provided, the manager is authorized to
make management decisions which govern the operation of the regulated facility including having the explicit or implicit
duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to
assure long term environmental compliance with environmental laws and regulations; the manager can ensure that the
necessary systems are established or actions taken to gather complete and accurate information for permit application
requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with
corporate procedures.
(2) For a partnership or sole proprietorship, a general partner or the proprietor, respectively; or
(3) For a municipality, State, Federal, or other public agency, either a principal executive officer or ranking elected official. For
purposes of this section, a principal executive officer of a Federal agency includes: (i) the chief executive officer of the
agency, or (ii) a senior executive officer having responsibility for the overall operations of a principal geographic unit of the
agency.
This authorization may specify either named individual(s) or position(s) that must have responsibility for the overall operation of the
regulated facility, activity, or environmental matters for the company. Please identify either named individuals) or position(s) (not
both) and then complete the "Facility Contact Identification Form "for identified individuals.
I certify I am an Authorized Signatory and am requesting the following persons/positions to be Duly Authorized Representative
(DAR) in order to complete reports required by NCDEQ permits and submit information requested by the NCDEQ Director on behalf
of the above facility.
Kenneth Elliott
I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.
Alvin R. Smith
Typed or printed name of authorized signatory
Owner / operator
Title of authorized signatory
Signature of authorized signatory
09-15-2022
Date

Facility Contact Identification Form
Facility Name: Facility Number:
If an existing contact is being replaced with a new contact, please identify the existing contact that is to be replaced on the
"Existing Contact" line.
New Facility Contact: Kenneth Elliott Title: Consultant
Existing Facility Contact to be replaced (if applicable):
Facility Contact Mailing Address: PO Box 112, Aydlett, NC 27916
Facility Contact Telephone No: 252-339-9021
New Facility Contact:
Existing Facility Contact to be replaced (if applicable):
Facility Contact Mailing Address:
Facility Contact Telephone No:
New Facility Contact:
Existing Facility Contact to be replaced (if applicable):
Facility Contact Mailing Address:
Facility Contact Telephone No:
New Facility Contact:
Existing Facility Contact to be replaced (if applicable):
Facility Contact Mailing Address:
Facility Contact Telephone No:
Facility Email: [e-mail]
Facility Email:
Facility Email:
Facility Email:
Title:
Title:
Title: