NCC216849_FRO Submitted_20211214

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 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 N/A in the blank.)
Part A.
1. Project Name CUSTOMERLOUNGE DEVELOPMENT
2
Location of land -disturbing activity: County CALDWELL City or Township LENOIR
Highway/StreetFLINT BRANCH RDLatitude 36.100 Longitude-81.601
3. Approximate date land -disturbing activity will commence: ALREADY STARTED
4. Purpose of development (residential, commercial, industrial, institutional, etc.): RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.72
6. Amount of fee enclosed: $ 130.00 . 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name J. DIRK NEWSOME E-mail Address [e-mail]
0
Telephone,
704-724-1446 Cell #
Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
CUSTOMERLOUNGE /J.DIRK NEWSOME 704-724-1446
Name Telephone
PO BOX 1512
Current Mailing Address
CORNELIUS NC 28031
City State Zip
10. Deed Book No. 2013 Page No.
8410 Dunmore Dr. Ste A
Current Street Address
Fax Number
Huntersville NC 28078
City State Zip
1516 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 or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
J. DIRK NEWSOME [e-mail]
Name E-mail Address
PO BOX 1512
8410 Dunmore Dr. Ste. A
Current Mailing Address Current Street Address
CORNELIUS NC 28031 Huntersville NC 28078
City State Zip City State Zip

Telephone [phone] Fax Number
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 City 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 exec e instruments for the Financially Responsible Person). I agree to provide
ammorte i rmatio oul there be any Chan in the information provided herein.
olow OWNER
o rint a e Title or Authority
Si Date
a Notary Public of the County of MQ C .y L'c kibLx
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State of North Carolina, hereby certify that �� �U� 1 Ui'1/L� 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
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