NCC192591_ESC Approval Submitted_20191031

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 for,,,
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 N/A in the blank.)
Part A.
1. Project Name 000 W
' ��yy� /
2. Location of land -disturbing activity: County 1 City or Township Are L&1_
Highway/Street & qpo V)eaA+ HOC Latitude 3S. 1 D_; JDD Longitude % /, / a 4P 9& 0
3. Approximate date land -disturbing activity will commence: lV%%Pde,w,.(3elz, 311 101 1
4. Purpose of development (residential, commercial, industrial, institutional, etc.): �s-�cvl -� 4
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): e9l•
6. Amount of fee enclosed: $ —y — . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes_ No Enclosed
8. Person tocontact should
erosion and sediment control issues arise during land -disturbing, activity:
Name_ Wtc,, �Q� ,\frA E-mail Address IniC��el gy,l kl�ffr
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.
A'c Aae /f v,;,( ow�e�
Type or Drint name Title or Authority
�%
Sig ature Date
l �� {�h. �f�r-� a Notary Public of the County of Ron&�
State of North Carolina, hereby certify that mt d-Xld ic9 RA'r-s 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 _30- day of + 2019 —
T M. WELOMN
� Notary
Se,MCOTARY FLmuC
County, North CeMiia My commission expires Co
lira Exalreu