NCC215261_FRO Submitted_20210924

FINANCIAL RESPONSWBKLITYYOWNERSHUPFORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any activity onone mmore acres as covered bythe Act before this
form and on acceptable erosion and sedimentation control plan have been completed and approved by
the Lend Quality Section, N.C. Department of Environmental C3um|Kv. Submit the completed form to the
appropriate Regional Office. (P|nooa type or print and. J the question innot applicable orthe e-mail and/
orfax information unavailable, place N/A inthe b|ank)
Part A.
1. ProjectNa -TclilU%rinlivi!2%215
2. Location ofland-disturbing CountyViewd AAamqer City or Township
3. Approximate date land -disturbing activity will
4. Purpose of development (residential, commercial, industrial, institutional, etc.).
5. Total acreage disturbed oruncovered (including off -site borrow and waste 11
6. fee of$6510per acre (rounded
uptothe next acre) haassessed without aceiling amount (Example:a0'acreapplication fee im$585)
7. Has anerosion and sediment contr_/ o|p|�nb�an�|od? YeeL_�NoEndosed_______
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Telephone CkW_5a�_ Z2(o Cell #
Lmndowner(s)ofRecord (attach accompanied page holist additional
Name Telephone
Fax Number
Current Mailing Address Current Street Address
State Zip
city State Zip city
10. Deed Book No. 9S 6.31 Paoe Provide acopy ofthe most current deed.
Part B.
1. Company(ima) or firm(s) who are financially responsible for the land -disturbing activity (Provide e
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.
Name E-mail Address
Current Mailing kdj-ress Current Street AddrQjs
City State Zip city J State Zip

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 'E-mail Address
Current Mailing Address Current Street Address
City State Zip 'E,7ty— State Zip
Telephone
Fax Number
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'1t Q�e�1c11"`.�fi�'
Type or print name Title or Authority
- 9 I IS- J-2— 1
Signature Date t
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CO 616 a Notary Public of the County of NeW
I
State of North Carolina, hereby certify that fll appeared
personally before me this day and being duly sworn acknowledgedQh t the above form was
executed by him.
Witness my hand and notarial seal, this day of 20 -2,
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My commission expires
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