NCC221347_FRO Submitted_20220405

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 Eazy Recycling Site Development
beson o
2. Location of land -disturbing activity: County r-"Ru — - ---City or Township Lumberton
91
112
Highway/Street K B Road Latitude 34.5967
Longitude -79.0668
Approximate date land -disturbing activity will commence: April 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):6
6. Amount of fee enclosed: $600.00 . 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— X No — Enclosed-
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Larry W Anderson E-mail Address [e-mail]
Telephone[phone] Cell #910-608-2808 Fax# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners), -
Russell & Edna Mayes 910-802-4375
Name Telephone Fax Number
1433 Snake Road 1433 Snake Road
Current Mailing Address Current Street Address
Lumberton, NC 28358 Lumberton, NC 28358
7-
City State Zip City State Zip
2272 830
10. Deed Book No. Page No. 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 patty,
Edna Mayes [e-mail]
Name
3185 W. 5th Street
Current Mailing Address
Lumberton, NC 28358
City
State Zip
Telephone [phone]
E-mail Address
3185 W. 5th Street
Current Street Address
Lumberton, NC 28358
City State Zip
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 3]p City State 3]p
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach m 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 otRegistered Agent E-mailAdd/uss
Current Mailing Address
City
Telephone
Current Street Address
State Zip City
Fax Number
State Zip
The above information is true and correct to the best of my knowledge and belief and was provided
bvnnounder oath (This form must besigned bvthe Financially Responsible Person if an individual
orhis attoroey-in-fact. orifnot an individue|, by an offioar, direobor, pertnar, or registered agent with
the authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information should there baany change inthe information provided herein.
Edna Mayes Owner
Type or printnenle Title or Authority
State ofNorth Caro{ino, hereby certify that _
personally before me this day and being
executed by him.
a Notary Public of the County of �j , Z,
ed that the above form was
appeared
Witness O0yhand and notarial seal, this daynf 20.
Seal OMM.
Notary 61
My commission All