HomeMy WebLinkAboutNCC223333_FRO Submitted_20220922MY Of Winston-Satem Field Gperations D"rUneilt. I Emsion Cantrol Divi-sOn
190 F- Fi= StYCU, Suile 328, -NC 27101
Mailin4r,-- PO 13D K 2 511. Win!4011-Sa 10-4 NC 27102
Financial Responsibility/Ownership Form
NO Pemtm F11aY inifivtt fitY kld--distzffbi;�ig af,�tmy 'U,Uoo I QDOO
Nljare feet ffir 24Y Ot[WF non-gA empt P[VPDM Or PWS of a byger conumq, pin 0
Wn YA4 Wo mxzogobwk Eroman Conri-ol plaft how bme MAM&y Ids* Warc qi!h
iltcd, m'Acwe�, and -approved by tim cjjy of %Wu.Q-SM ekp 1:rosjon
CLIMMI Divi:6ou and a (h2ditWEtusion Ceittirol pump ho own IW6
mol.appfi�Elhle, tyPe "tt 010 "KA" Ua We b lait space if
Part A
N.4= Name - .... re, -qj. Ld, e
_, .,� ...... w.,.�.. �.._....,, ..
Giradi"iisi,xi conqf Permit
. .......... 11- .. . .... �V.� .................... - ..... ..........
� k.
W?14550g. Activity wig Cvmnlenc5L,
popmm OF GnMg:
Commooll EJ Widwidal Rk�Admkfiol
Residemiaj
.. . ... fix-tvatt zu bt VistL�,W:
Fee:
person to conUet "h'Duld ETOMOn Cftltrul reia ted &sues arise du ring land-dbturbiag A"i'vities'.
Nan[w. ..—Tu .a.. -zL . ..... Email:
"P .. ......... ..........
Chka
Landowner Of Record: 4e,se hjankpgge 1.0 hyl addiM7haf owners if r;fruJ'&#
Parcel PIN 6--l? (i S, .. c� 3 -
......... TRx Block-4P
Nam':
Slrtwt Ad&esVP6 $ox- ., �� . ,., +. .,..,.,.� ,.,,..... ,.�.. �. a, ..,_. »....,, �,, ....yy,,,..,-......� ...,...... .. ..
City1� Irfzip
. ..............
27
Gradift Caii tractor Informatjoi!k: (I
AAeb.rPVSj49q COMM) P?GA for p4l Vie W)
VaJUU Of GF'11f� r] g Contract, j . ......
NWUW of Grad*' . ..... . ..
COVem CInw. PiL
Sms! Ad&,70 .14"! .... . ...........
City/Smelzip C607
part B
rorwa(s) or Srmg Who are IISnanci resp bte f".t'his wnti-di"Urbing;P jsfty' (use blao page #a.list mw Ftiolml
pexsrns(s or if need} •**C&ntrJ0E-m are rbut- arnsid=d ftant: jolly respaaj�kblt� f�r Propcfty not +s der ikb- asw=rsttip***
N=0 Of Pt' Non or Firm. Zv #
cily'stneziij
{, .. ............ ... .... ....,.... ......... ... w 4 .........
Office Phufle,
mobile
ff the fine ,iaD' mpoorXible r(y is a3l out-af s#u#e $rlti, provide Wormatioa far the-jnrstate r"ggfertr�d uZt:nt:
NartteOfll Z9hgtmd Agent ...............
Strj:W Addm9LVMB x:.....,...
......
O e'Pho t ... .....................»...................... k4abrlt= Phone- -.. ... , ....._. ,....., ......
It the itimanemy -riDspmtotbte Party i!' a Par" 'O&lsitp, prov'de imIOrmatort (ur eUh Gewat Partner -
(use bf&ci a JP lost add4f pQVj1,;n if'n&d05
N4EW of PegiSttred Agent, .. + ,.+ .. ,.-. +, ..r.........,.. +,
.................. ..............
...., . ....... Y..... ....+.......... .. n........... � +.
0WISt"e14 Cade, ............................„
offit:e i}h4ae; w.� :. .................y. .' alai) a .n. . , ..... ... � . ......
Vie: ....., .. ........ �...,... �,.,,t i��x �:.. �..,...�. , .+....._..� ...,..... ...,.
The above In nn is true and iS'=W to the hc9L Of MY krrt lfx : WW bL I icfand wa.%-PTPvi&d by rile tJ&er aath_ (Tbix form
t l!oigr,6d by the financiAlty resWz1sibW persom, if On individual, of their 01 i'f not ion itrdivit3w, by an cer,
frurtncr, 4w regiWm€i 6gmt vitb 4stqitx• to ,.cM it ttutr,e ttss t the T,rarttciaEl} res �nsa3�ftr #teF �rF_} i to provide
curreeted iuRwnw6onshoWd there be Hmy chanw iFf-t iBfbrmation prt Oiled heist.
Typz or PTim Name,
i#fit i1I Autho ' ........., ,...... ,. ,.... .......... ......... ...... .. ...
public`. ofnil,....
heichy wrtify that ...w
(xr_rsanally beftuC me this day, and being duJY-swam, as k-nowicdged slut the ab vc fa,•n, was L-AVOUted try himhu. Win ", rnjr
band and nmia641 seal, $his : Q... ��,
... .,..;:..... .,.......+ .,+...,..... V ... day of .,.........,,»..�... .�5..:.... . 20
DORISNotary Ptiblic-Nawc:
CHARMAINE JACKSON
Notary Pub4c. Siguamm `M.�+ +t NOTARY J I�BLfC
• �„ Fofsylh County
North Carolina
My ropunbislaTJ�; •••�� •, .�.•. , �.�.,.. l� Cammiio Expires Atafch 14, 2M