NCC223452_FRO Submitted_20221006

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"FORM.
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RIERS
-0 R SPON
FINANC.
SEDI'.NIENT�"�14N.:RC��:
LUTION COU.OL AST
- "-ON
E�.PRESS.
PE�N��T'TING`
C d eore
-.:act r%. Pre:'0
ivity br( Metoedqpprov6d170C 'e-dOmPform tman _ N.SO Ah1: Plan --hav-P_ -and
.No pprsgn may initiate anyland�disturi�ing
his forr�C-opt6i and an,
-Env�rcsnme�#al tuall 0nit letod-or the'`.-e7M;0.9. V10p:n..js n6t. appficable.by:th.e:� La0
Reg ona�r�n#::and,
I
thy: ap�:.gpradd�-es��ori�t�-
th-bI0nXJ
-'-phohe M 4'11abl.'p1�c�:.NIA,:�r�'
- :' - - hu 'bibr]' nav
.-s
-. ante; Afte��Th' dfitro"'I Plan.. 'f6r- Ra)ddr. 276- Site JRAN)2n 000Laca�ionof.lari�#-di�tur�i�ig�actiu�iy
County�T„� &va�ffla�- civ. ot -T fth!0 Dunns Rock. -7�2$7�.-R-2-�j.
'0.�Wd6(dereaa­. A. -
Iatitu de(dkimal degreasl 3,54, Lo n
T�ur�jLer, Rd'
Htghw�yf5'tre..e,�
-.2QZ2
M0ncwav
landAistUrblAg C
14proximate date
31P
-.Site
IP
Industri I JntfiW`00r, etOl4;� .,Purpp*-,0f'devel�prn���:ires�de�itial;camm�erG�a1;
S
offsite boRtw+� and, waste areas)-
n6ludlhg
b4ge 'd, ar,uncoverethed Total,wr _-d ittu-
P0 .0119 -aPP"cat'on -foe..is .. a dual,
Mit The ExPres
$e#wlthOut-a -.9
6f fee--anclos-ed 47-000G: 0 -tho ftext:ac -asses.;�.,.:� :0�
T �ra,�r�ded'.up�.tA M."OlAt, - - - - -:.''rjj�yj!g
er acne:p..to e1g. . acre% after. whiCh
.0 arge:-p .;acre u %_htof.-II..0 P.hemen - :Or.
.kp -,.r>s. Permitt}ng.apRlication fee i�
10h.. hb.,E res-UPPI
�moi��tit, in (Exarnpl�: -.8,
���000:�]
fixed
.(pros P�rmittir�g. supgiarrment�l=fee: th Ej
��F9'Q.p).:Ch�eck�h 0'00-000a�Oed bo NCDE.00" s.-OUI
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Has--oo erosion - and.:sediment tQntr0I- p�an:b�.en fil0d? Yes Enclosed. No
T..
:Person:'"
8Id Show1d. erasion -an : .sediment PQO#91- Issues arse daring. Ian is. ux lng-:
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, itym
­1 'ddiess
Ixter E-mal
Name,..,S
J. -$�$-��G�Q25`1-
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Phone.Officer
'! -..to listaddiflohe' nor-S,
(!�)--Of..Rec (ai�ach
Ord...accompan!,e .d.:page.
..8-28-226^02-511%
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Mdbil'
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440-1-`SivLers ft_,--R�d.
.1101 Siive!§Leg�n Rd Current:S#ee.t--Address-
M�ilin�:Addr.E�s'
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tur� a 'it(i�ravide-a bOmPrOPOweons��t�a�e lapd-dis efiv Y;
'tiny'(who�are`fM.. Jqing.
-anccoMpany..,M.61�610 Ompri
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tw.! I
mpan!W pm(�ip
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"r�spons�ble A I,. ).. �!hOfipOP640' paity,06s)
listed
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-mail-A.OM '
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PhonE: Offic�.:#
`ncludp w this.
land to, be.Aisturbed,
owner
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p �a�t�vity:
t to sUbMft--:O-- draft erosior�.and'
�lf�,th�:�Finariciatly.R�s.�onsabi�s,.n
Ot.,; -:0WOWtia Palty
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w n: �nsent..%rlha ap 'lica
--a d,ftted. ttsigned
form�:the- -WhdOW0.
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Oodfm"
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p togistered' cn. the NG -Socretary.-
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Fina�c�aliy:a. it.. the Respan5ible
- .. . ii�e Acleht-'its--6(the RegIstered�,.:namo
bu iness r..egstiy
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Name:of
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Mobile #.
Ph'Ohelm,-.'Office;#
Register�d�.A9e�n#. is a.compan
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Name:.af �i�div..adual"to..Corita�t,
-ttrppt add're'ss
o�tCarol�na,::9N..State - usiness regitry:
G $W-r-6tOry
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ibie:'PartY i hb. a te­611-RFkGj yon -the N[ftho Rha" Pd:
Is Ot6d Worth Carolina.wentwho .1$ Mg..
of th�646 "J.9P
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Namr� of Individ'uW:t� Con�aCt try R�.egiS�,re�i A�ent,is ���ompany
is. en a �nqin busmes� �urid�r a��, :�ssum�d �am�; ..give. name
c 1� the .�inanci�ffy Resprisible'-.Party. 9 _9
under" . ,wYii�h the �orr�pany is� Deng; Business As. �!f #he; �inan�ially� Responsible, Party �s: an :indrv't�.�al,.
General Partn.er%%hp,:-,Or other- pany riot r�gi�tered' �r�d :doing bu'iness- .under.:an .assumed harr��,
attach a copy of ihe=-Ce�i�ca'�e °v��Assumed Marne.
CO,MP.anv-:OBA- NO M-e .... .
d :l�.�r�ci�r to facilitate, Express; Pe�rm9tti�i� . it"J,s necessary tv��he-able Wta� engineer o othc�r
cansul�n# wha can -assist in providing �ny.neces�ar� in#Qrma�o� ��9�rding.fihe.:pian-�nd:i s prepiirafidn'.
��ti�i�teering �rrn `a� other :consul
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8-mail. -Address -
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Ph
onwOffjqp-#­ MOUlle,
ia .divd
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prpv�d
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"f -an. inthe �ria ci
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'ittoted -OgPnt--,. We y change in. the
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informabon.-Ot6V'de ...re
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—"� MAMA err
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state ofNoah C
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lln6I h0rOY :certify .that .. - ...... C'. A-.. Yr-1
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appea
,: me #� -:dad: �n�d � being ��ly sworn �. w, :. d h�t 'tote abo�6:`�'n . as
�per�sor�.aily before . .
executed by"himm�r.:: �
I1lll'iiness: my�viand �an�:;nu'�ar�ai: s�af, t%i�=. : -: dayof
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