NCC221996_FRO Submitted_20220527

FINANCIAL RESPONS1131LITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No Person maY initiate any land -disturbing Havity on one. of more acres ai� cov red by the Act befbre, this
form and an acceptable erosion and sedimentation control plan have been completed -and approved by
the Land Quality Section, N.C. Department of Envlronmerital Quality, Submit the completed form to the
appropriate Regional Office, (Please type or print and, it the question is not applicable or the e-mall and!
or fax 1 nf o rm at lo n u nava i table, pl ace NIA in t he b [a In k.)
Part A.. III
1 � Project Name 4 Jd)-aa-5, LkO
V 1
2. Location-ofland�digtutbin.gacflv.4: County_F_Ldft_)V1_�) City-orTownship
Fran )I Lh-Lftu
HI hWaylstreet,_ U � PLO U J_ Latitud 0 1 a
9 e A -64 00 IV Longifude 7,6
3. A
.ppjro:xima1e date land-disturbilng.activity Will cornmence
ID
4, Purl)Osebf development (r�esidantlafi dommerciol,industTial, J st tutional, etq-
P 1.
6 TotW::acre.Rge.dlsturbed or uncovered �(includlng off-sife borrow,andw.aste weag)-,
too-
6_- Amount of fee enclosed: The application fee Of $6-5-96-peracre (rounded
Lip to. the next acre) is assessed without a ceiling amount (ExaMple: a 9-acre applicat[on fee Is $585).
7. Has an erosion and sediment control plan:been filed.? Yes No: E nclose
8, Rerbon to bontact should erosi' and sediman't control lssues adse:during I I and-distabing activity. -
oh
Name �614ngffld HQf" RAF, E-mai.!�Addressy_hAITML)n�Q a P-Lmy. eo/yl
Telephone Cell. qlly-
1A,6.0 Fax #
.9i Landowner(s) of Record (att ch accompanied pageto:11st additi
a 6nal owners),
44-4,U-1 q
Name J ' Telephone
�31 Q?a.m'ec gar —/—
Current Mailing Address
r, &1� )L- '6114- 'fAo /0
city V State Zip
Current 8treetAddress
State
Fax Number
zip.
). 1/1 A
10i DeedBookNo, '7&F- Page No-.. Provide a copy of the mIant d eed
Part B.
1� Company(jes) or Urm(g) who. are financially responsIble for ihe. land4sturbling activity (Provi . d9i a
oomprehensive. list of all responsible. parties on an attached. shaet,) If the uompany orfirm is a solaproprietarship,
tho.name of tho owner c;r wanager rnay, be fisW as tha. rb?anelaily respah sfblvi ppriy.
(111D P1610ti-oa 611 OvAll rak I/
Name J &rnail MlTress r
&rrment �Mafflng iA'ddress
h 9
a I
city zip,
Telephond, g- pq,
. v
Current StreetAddress
city State
Fax Nu

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
Curreft Mailing Ad - dress
C ity
Telephom
E-mail Address
Current Street Address
State Zip GAY
FaxNumbe
SW0 zio.
(lb) If the Financially Responsible Party is a Fartniarship or other pamori engagfng in business under an
assumed name, attiich a copy of the Certificate orf Assumed Name. If the Fin.anpially Responsible
Party is a Corporation, g [Ve� name' and street address of the Registered Agent-
6t I y- OVe I, yVN.(_'Drv-)
4—ame �of Re �Istered Agent -E il I �Am S s� _J_
;,316 Nroir- Ro
Curre.rt Mailing Address
:City _If 'State Zip
Telephone. qlq- 4�51)_8363_
Current Stre.at:Address
Gity . State,
Fax Number
The above information is trueand correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by-11he Financially Responsible Person if an individual
or his attorney -in -fact, or if not an indivAual, by an officer, director, partner, or registered agentwith
the authority to execute instruments fbr the Financially Responsible Person), I a . gree to provide
corrected infoirmati" should there Wany change In the infor�matidn provided herein.
DAtj le-
Typ Azoick 1-4
Tffle or Authority
Wgnature - Oate
Le- A.,Notary Pdblib.0 the County. of W"-&
State of North CarolIna, heraby cerfify-that -appeared
personally before me this day and being duly sworn: acknowledged that the above form was�
executedby him.
Witne;ss' my hand --and notarial seall, this da of
�y
C. ALLISON FOM
NOTARY PUKIC 4.
va a ergv mmm w qota�V
MY dommi6sion expires