NCC217117_FRO Submitted_20211222

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered hV the Act before this
form and an acceptablecontrol
the Land Quality Section
erosionandsedientation
N.C. uepartment of Environmental Quality. Submit the completed form to theappropriate Regional Office. Please
Dian have been rnmnIp-tp-ri ar,ri a.,....,�.e.a k..
or fax informati
on unavailable, place N
Part A.3501
1. Project Name
2 qw
3E
type or print and, if t
/A isn the blank,,)
Moon Lindley Road
Location of land -disturbing activity:
CountyChatham
Highway/Street Moon Lindley Road La
he question is not applicable or the e-mail and/
t*ltude 35 a 8344
Approximate date land -disturbing activity will
4. Purpose of development (residential,
5. Total acreage disturbed or uncovered
6.
7.
Amount of fee enclosed
$ n/a
(rounded up to the next acre) is assessed without a ce
C40 ity or TownshopSnow Camp
Lonaitude 7904128
commence02/15/2022
commercial, industrial, institutional, etc.).esidential
(including off -site borrow and waste areas
)03a62.
The application fee of $100-00 per acre
fling amount (Example: 8.10 ac = $900400)0
Has an erosion and sediment control plan been filed? Yes X No
Person to contact should erosion and sediomen
Name Al ison Blacks
Telephone [phone] Ce
Enclosed
t control issues arise during land -disturbing activity:
E-mail Address ab@a1liusonblanks.,com
II # 3364231429
Faxmmnw�
9. Landowner(s) of Record (attach accompanied page to list additional owners
Michael and Allison Blanks
Name
98 Bridle Path
Current Mailing Address
ittsboro NC 27312
3364231429
a
Telephone Fax Number
98 Bridle Path
Current Street Address
I s oro NC 27312
�Lr Mate Zip City State zip
10. Deed Book No.2149 0818
Page No., Provide a copy of the most current deed.
Part B.
1. ies) or firms) who are financially responsible for the land -disturbing activity (P rovide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole propnelom�llip,
the name of the owner or manager maybe listed as the financially responsible paity.
Michael and Allison Blanks [e-mail]
Name E-mail Address
98 Bridle Path 98 Bridle Path
Current Mailing Address Current Street Address
iftsbo ro NC 27312 Pittsboro NC 27312
City State Zip City State Zip
Tele one3364231429
Fax umber�

I?
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agents.
n/a
Name
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
Fax Number
(b) If the FinanciallyResponsible Party i*s 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:
n/a
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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.
Michael and Allison Blanks
Type or print name
Signature
Owner
Title or Authority
2' 2oft
21
Date
40 a Notai Y e County of
Public
State of North Carolina, hereby certify that
personally before me this day and bein
executed by him.
Witness my hand and notarial sea
N/20
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I, this day of � fie.. , , 20 21
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Notary
My commission expires,
appeared
form was