NCC220372_FRO Submitted_20220119

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 NIA in the blank.)
Part A.
1. Project Name .S414a p o>4 ce-eej~ C-L>T 1
2. Location of land -disturbing activity: County City or Township dew! dtLL
Highway/Street,LW Latitude 35. U5 La$ Longitude �q. 98DCa
3. Approximate date land -disturbing activity will commence: Z' 1 /Zoz�
4. Purpose of development (residential, commercial, industrial, institutional, etc.): PC- e4 —
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1. 3
6. Amount of fee enclosed: $ 2-00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900),
7. Has an erosion and sediment control plan been filed? Yes )4 No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name �Ja�c>+� I�L'Nnl>>►lGS� E-mail Address�n'1" SQr � r� ` �;,..
Telephone Cell # g1q`30b V5V1 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
10
C�r4 SS! r�7/ G�rY'� p7DI�/
Name
gco28 L,}uR-cL_ LOEr2i2-4 sr
Current Mailing Address
City
State Zip
119-451- 0410
Telephone
Fax Number
co Zig Lrr4"042_L- cr / Sir
Current Street Address
9A-IUIC-1f+ AjC' 2:7 C04 '7—
City State Zip
Deed Book No. 2-1g8 Page No, 1-76
Part B.
Provide a copy of the most current deed.
Company (ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Goss, Orr-►PT-b,%l C4:,m P7D V E- y,4 Hcw-')—
Name E-mail Address
Z.0O2$ LAIC+-- Cry ST ?_La7-0 LA4_&:L_
Current Mailing Address Current Street Address
�r &'114 N C _ Z-7CQIZ -'P_.4L-4E1C'1t-E-' AIL- 1, -1 Lo M,
City State Zip City 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 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 execute instruments for the Financially Responsible Person), i agree to provide
corrected information should there be any change in the information provided herein.
Type or pit name Title or Authority
r 1
Signature C Date
I" ���� ,1�� �- � a Notary Public of the County of Wei/< 6
State of North Carolina, hereby certify that C�{Sry ��14", appeared
personally before me this day and being duiy sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this Ib day of ITIV164^4 20 1 Z —
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My Comnj. E
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5-2-2024
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