NCC221972_FRO Submitted_20220616

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 NIA in the blank.)
Part A.
1. Project Name �� - n 4 Cod i {_ ci-- t4/4_S
2. Location of land -disturbing activity: County,_ C /u/ 6V5 City or Township
Highway/Street 1(0! ?U at{ ro 101 WLatitude 3L1.33 31 Longitude _7Y, W
3. Approximate date land -disturbing activity will commence:_11)} 4 20 Z
4. Purpose of development (residential, commercial, industrial, institutional, etc.): c �.rrerCf
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): /o
6. Amount of fee enclosed: $ 170 . 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 4/plNo Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —TO " — �t " F--", /e- E-mail Address_- 2egt 1,E 4�2 d�V - LV•1V"A _ Corl
Telephone_ _N 21 Z - 5 9w'O Cell # _ Fax # .
9. Landowner(s) of Record (attach accompanied page to list additional owners):
l_-f 20Ll :,ZOO
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State Zip
10. Deed Book No. .___1_�-7� _ Page No_ H i? --_-- _- - Provide a copy of the most current deed.
Part B.
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):
- _ S J _ . � - f�-G ' S'.vn
Nam E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone . _ `� �. 2 -,z F_�/ 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
Current Mailing Address
E-mail 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 State
Telephone
E-mail Address
Current Street Address
Zip City
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.
Type, r print name
Sightiture
-e r-
Title or Authority
S Z
Date '
I, UW04A \J UY--C , a Notary Public of the County of "-' _
State of North Carolina, hereby certify that VA A-P & appeared
personally before me this day and being duly Aworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,
Deborah Jones
Notary Public
New HaPOOr County, NC
My Commission Expires 12102l2026
W
this 23 . day of
Notary
F
My commission expires 1*)-- o �"o