NCC223090_FRO Submitted_20220831

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 NIA in the blank.)
Part A. Twin Lakes Lot 19
1. Project Name
2. Location of land -disturbing activity: County Union City or Township Matthews
Highway/Street 114 Pecan Cove Ln Latitude 35.02082951713423 Longitude-80.69730043552956
3. Approximate date land -disturbing activity will commence: 912022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residental
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): '53
6. Amount of fee enclosed: $ 100 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Leonard & Kamari Green E-mail Address [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Leonard & Kamari Green Brookfiled, WI 53045
Name Telephone Fax Number
114 Pecan Cove Ln 19750 Heron Pass
Current Mailing Address Current Street Address
Weddington, NC 28104 Brookfiled, WI 53045
City State Zip City State Zip
10. Deed Book No. 5509 Page No. 0495 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.
Leonard & Kamari Green [e-mail]
Name E-mail Address
19750 Heron Pass 19750 Heron Pass
Current Mailing Address Current Street Address
Brookfiled, WI 53045 Brookfiled, WI 53045
City State Zip City State Zip
Telephone [phone] 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:
Nla
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:
Nla
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.
Leonard & Kamari Green Owners
Type or pr' t n e Title or Authority
Signature Date
lr� "//V- , a Notary Public of the County of h hN
6d ec'v,^
State of , hereby certify that Le#404 6n appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 23"'L day of JrA
TYLER SCHALLER
Notary Public
8616I of Wisconsin
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J
ary /
My commission expires���3/z�