NCC215504_FRO Submitted_20211005

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 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 and/
or fax information unavailable, place NIA in the blank.)
Part A. East River PH 6 & 7
1. Project Name
2. Location of land -disturbing activity: County�ohnSton City or Township Smithfield
Highway/Street Buffalo Road - SR 1003 Latitude 35.5350 Longitude - 78-3303
3. Approximate date land -disturbing activity will commence: 9-29-2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.70 AC
6. Amount of fee enclosed: $520 . 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? YesXX No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameNick MCKeel
E-mail Address nick.mckeelQprovidence.00nstruction
Telephone NA
Cell # 919-429-0245 Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Buffalo Road, LLC
919-901-3178 NA
Name
Telephone Fax Number
114 W. Main Street
114 W. Main Street
Current Mailing Address
Current Street Address
Clayton, NC 27520
Clayton, NC 27520
City State
Zip City State Zip
10. Deed Book No. 5203
page No. 208 Provide a copy of the most current deed
Part B.
1. Company(ies) or firm(s) who
are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company orrrm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
Buffalo Road, LLC
[e-mail]
Name
E-mail Address
114 W. Main Street
114 W. Main Street
Current Mailing Address
Current Street Address
Clayton, NC 27520
Clayton, NC 27520
City State
Zip City State Zip
Telephone [phone]
Fax NumberNA

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
Telephone
City
Fax Number
State Zip
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.
Reid Smith Managing Member
Type or print name
iAd=5�L
Srgnature
Title or Authority
9/29/21
Date
I, T21 l , a Notary Public of the County of�
State of North Carolina, hereby certify that W, 6 'k 'fl appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and 9,tarial seal, this day of , 213�
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