NCC223420_FRO Submitted (2)_20221013

FINANCIAL RESPONSFEIEFTYlOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may lnitlate any land- disturbing activity on one or more acres as covered by lhe, Art before lhl5 form
and an acceptable erosion and sedimentation control plan have been oomplete'd and approved by the Land
OuAllty Sartlnn. N,C Departmont of Environmental 00rility. 5uhmit thA rnmrlgteri form to the s+pprnprinto
Regional Office. (PWase type or print and. if the question Is not appl"Wa or the e-mail addfess or phone
number is unavailable, place NIA In the blank-)
F41 i A.
9. ^valid NsmalVIOT 1J Blast Berm ❑esian
/�e1y/} Y k .., ,.Brunswick rY+ r/ �,,,SmilhvilleTownship
2. Luy4i+},.1 ,,li 11NI Ike .v,�i r1.,{� YyiY It . VVLFi{Y y� k�y o 1 M�!<nah'F+
JTAM/�}�
3+►.r#t aaag 7 74
lai�kL}Y�l�rr�l r eHf �I Y�age�(.,,{�-V�G4gi Ma] I e�n�lh+r`n�G4Gii�+;djY.u+..��_
22023
q Ar}nmvimLstq �I{s#4s Iwf+r1Ilf�irhln Prfi��iFF Will Pnr»mar�Ii� a'
d Pirr1•nnn of Onyo.Pnnrnpnt O¢slfinnOni rnmmflrr:lRl inriIntriai ini;ftifinnul. Mr. }• OperatiorlallUS Army
5. Total acreage disturbed o•r unaovemd eincludina off -site borrow and waste areas): 411.9
6 ► mount of fee enclosed: $41, 00 The anvhc.atlon fed nt S100.00 Dor acro(round erl
tip to the next acre) is assessed without a ceiling amount {Example; 8.Ia-acre application fee Is $900).
Checks should be acddressed to NCDED.
7. Has an erosion and sediment oontrol plan been filed? Yes ❑ Enrk d lA No ❑
8. Person tocontactshould} erosion and Sediment control issues arise during land-dlsturbing activity:
Ram" Ql1f[ Y► l t i $ E-mail Add ress16Vi4AY1[.W,.irelis.C++iV(!PAn�•Mt
Phone: Office # 6i I O - { Mobile # TI D �5.1 ~ =F) L I
9. Landowner(s) of Recard•(auach accompanied page to list additional owners) -
United Mates of America [phone] NIA
Nu mu
6280 l,nnV Point Rd
Current Mailing Address
Southport, SIC 28461
rnollo, oike 4 mobii9
6280 qtjnnv Point Rd
f
Current Street Address
Southport, Pic 28461
10. De -A eon :k Ne 189 Page Mc 51 i}r� li rin 2 n f 4hc m 4 iurr nl

Part B.
I. Company(ies) wlio are financially responsible for Ole land -disturbing activity (Provide a comprehensive list
.~f III respnnn�-ihlo'?=teg on ecce1np3nied '^mn MIA it 3 � Iz . nr«+VyMrohfn nr��rlh�
are individual(s), lire rier►ofsS) ollhe owr;ier(8) may b& lrsled as 1ha Fieiartcidlly fV5P0+P5il a F,:u1y(iea).
Company Name
0orrant W111nn Adrircfeg
City State Zip
Phone: Office #
E-mail Address
0irront Str"t Addrfisa
City State Zip
Mobile #
Note; If the Financially Rpsoonsrhlo Party is not the owner of the land to be dialurW, include with this form
the landowner'& signed and dated written consent for the applicant to Submit a draft erasion and sedimentation
conlr0l elan and to conduct the anticipated land disturbino artl0ty
2 (a) If the Financially Responsible Party is a domestic company renisterpd on the NC Secralary of State
business registry, give name and street address of the Registered Agent;
Name of Registered Agent
E-mail Address
Current Mallinq Address Current Street Address
City State
Phone: Office #
zip city
Mobile #
Name of Individual to Contact (if Registered Agent Is a company)
Stale Zip
(b) If the Financially Responsible Party Is not a resident of North Carolina, give name and street address
of tho dosignalod North Carolina acgani who is registersd on the NC 5sr;rotary of State husiness registry:
Name, of Rergislered Agent
E-mail Address
Current Mailing Address Current Street Address
City State zip City Stale Zip
Phone: Office # Mobile #
Name of Individual to Contact (it Registered Agent is a company)

(c) If the Financially Reeptwtsible Party to engaging in business under an assumed name, give name under
w1II,,.II ilia willijaliy lb L'AA'11V auailitlaa tw. if u v irnlam inny i1C;apuimou1G raliy Ib cm mumuuai, GutiCIai
Partnership, or other company not registered and doing business under an assumed name►, attach a copy
of the Certfflcaft of Aissumad Marna.
Company DBA Narne
The above information Is true and c onec:t to the best of my knowiodge and belief and was provided
by m{� i rover oath rrhic fnrm mi tqt hQI tInn prl by tho Finanr*Inlly Rocinnnczihira Psarcnn ifan inrOuirlvial (a)
or his attorney -in -fact, or If not an individual, by an officer, director, partner, or registered agent with
the n..{hnr:{.e �..nn� �{!h �nnl.-�.r.,� 1r• �nr {M,A, �ir7n�hir,ll,r %nf*nnnniltiln Pn'ir�) I nnrnn {n r+rn*ndn
...r. uti.�.v...r . vury � ..+�. .+��. .+.+ ..r. ...y , M Y.Mu� \Y�I{I VIIJ�M.Y w�*jj. . uy. ti.Y ...+ � v•�yrY
corrected information should there be any change In the information provided herein.
Adrienne Rogers
i ype or print n8 8
Siqnature
Environmental Compliance Officcr
I Itle or Nutrlonty
Data
I, '1ti ('-A, n i Duu1 , a Notary Public of the County of &kwi )Qv
State of North Carolina, hereby certify that i�kf'trp- , appeared personally
udiurti 111ti H i b clay di lu Ut#u ill Liuiy t wui I I dt.i%I IUwit�uyuu 6 WL 6IL' t VU IU! III VVdb WMILUitili by i II11 A wi .
Witness my nano ana notariai seal, this \45 oay of:OPV-
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My commission expires b4