NCC220495_FRO Submitted_20220217

FINANCIAL RESPONSIBII...ITY/OWNERSHIP FORM
SEDI ENT T O�LP OLI...UTI N CONTROL ACT
No person may initiate any land -disturbing activity on ca a or more acres as covered by the Act bef this
form and an acceptable erosion and sedimentation control plan have been completed and approv by
the Land Quality Section, N.C. Department of Environmental Quality. Submit the complete m t%a,
appropriate Regional Office. (Please type or print and, if the question is not applicat_pr the ail
or fax information unavailable, place N/A in the blank.) ooF�daQ�
Part A.
1. Project NameSpencer V )
2. Location of land -disturbing activity: County @,1;ton City or Township Dalla*
Highway/Street Dallas Stanley HWY Latitude35.326776 Longitude-81 . 146907
3. Approximate date land -disturbing activity will commence:November 2020
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Emergency Services
5. Total acreage disturbed or uncovered (including cuff -site borrow and waste areas): 4.24
6. Amount of fee enclosed: $ 325 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 filled? YesX No__ Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameDavid Flanary_ �:: mail Address [e-mail]
Telephone[phone] _ Cell # 704-689-1349 Fax # N/a
9. Landowner(s) of Record (attach accompanied pane to list additional owner's):
Spencer Mountain Road VFD
'704-922-4747 N/a
Name
I"elephone Fax Nurnber
PO Box 504
1011 Dallas Stanley HVVY
Current Mailing Address
,:::urrent Street Address
Dallas NC 23034­ 0504
Dallas NC 28034
City State - - Zip
4:;ity State Zip
Q
10. Deed Book No.4 Page No.2,41 1 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.
Spencer Mountain Road VFD
[e-mail]
Name
E-mail Address
PC Box 504
1011 Dallas Stanley HWY
Current Mailing Address
Current Street Address
Dallas NC 23034-0504
Dallas NC 28034
City State R Zip
o:,ity State Zip
Telephone_704-669­ t49
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
Current Mailing Address
City
E-mail Address
Current Street Address
State Zip City
Telephone 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.
Flanary David Fire Chief
Type r print name
Signature
Title or Authority
9/23/20
Date
a Notary Public of the County of G7 G oh
State of North Carolina, hereby certify that a V 101� G n.a ru appeared
personally before me this day and being duly sworn acknowlejdged that the above form was
executed by him. y,
Witness my hand and notarial seal, this 6-tti day of ��"Iyb'c'r , 20 20
JOY SELLERS-SPIRLIN Not
Notaf'yAblic, North Carolina
Gaston County My commission expires-- htij 54 2 0�3
My C m is ion Ex Tresis - —�
-.