NCC220507_FRO Submitted_20220126

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 Environment and Natural Resources. (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 Tarborough Ridge Subdivision
2. Location of land -disturbing activity: County Franklin City or Township Youngsville
Highway/Street
3231 Tarboro Road Latitude 35.9757 N Longitude 78.3701 W
3. Approximate date land -disturbing activity will commence: July 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.0
6. Amount of fee enclosed: $ 585 . 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
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Dan Tingen E-mail Address [e-mail]
Telephone n/a Cell # 919-422-2576 Fax # n/a
9. Landowner(s) of Record (attach accompanied page to list additional owners)
TRNC Development LLC
919-422-2576
Name
Telephone Fax Number
8411-121 Garvey Dr
8411-121 Garvey Dr
Current Mailing Address
Current Street Address
Raleigh NC
27616
Raleigh NC 27616
City State
Zip
City State Zip
10. Deed Book No. 2243
Page No.
269-270 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are
financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible
parties
on an attached sheet):
TRNC Development LLC
[e-mail]
Name
E-mail Address
8411-121 Garvey Dr
8411-121 Garvey Dr
Current Mailing Address
Current Street Address
Raleigh NC
27616
Raleigh NC 27616
City State
Zip
City State Zip
Telephone [phone]
Fax Number n/a

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.
Dan Tingen
Type or rint na e
S[g ature
Member/Manger
Title or Authority
4//2021
Date
I, h� �_ �, a Notary Public of the County of k) a
State of North Carolina, hereby certify that n a n —%i n S e, , appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my ha�q pp
,d notarial seal,
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Seal _
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this day of rt-,rI'Z+z 20_�Jl_
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Notary
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