NCC223580_FRO Submitted_20221026

7
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FWANCIAt RE/PONMUnn TI►I+OWNa�RaM
it - RI M
RDWRTATWN POLLUTION CONTROL ACT
Nt*Q OdMty an am or more arroa an cavwml " the Act bW* this kwm
OW an
0rcltdn, N.0 sadln+orthow eofeA PIMI have talon mmpWW arxl apgrrly� by tt7e t and
Departma of frA*onenertirwl txauty Submit the anrnpteted loan to "" nppnyprrale Rooksna! orke. {plarae type or Pft and, If the Ittlov sllrar rr �►r afrPNpttsre tx 111e a MAIN findld fors InMrenMllnn
un&vMWe, PIN* WA In the blank.)
Part A.
prt7facs Nome A�
Lacadon of ly Cou my CL Lj kAj-_j I Crty rx r ownatap L.1r1 V 11 ! :IV
tk
� r (�(. -t. at#udis . V t c n",de
AppmxiM W dole tancf.d ObOt trq adtvlty unit COmMe rce.
Rarpa00 of dw*pnlent (resldwrtlal, CommtxWclnl. Industrlal, Inatitutlonat, elc)
Total am"," d*Ubed Or unecovored (kctuding aft -site and curate areas)
Armor nt of be onciosod., s � 'Sc� x{ iy o a !
Up 10 go roW WSj is� wiEhaut a cei � lan fee of x 100 OQ per sus (rWr4W
Ornount (Example 8 10-acre appkcatbn tee is sow)
W■s an rooton and sedimsnl control plan been filed? yse V No
ErrclOred
Par*on to OOn!/d should
erosion and sediment control tastes arise during land-
hirsnt� • ___ �_, „_ .4_ _ E-mailAddress �� I �
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cal aM .���. =��4 .ct�,t� p
$. t-andowrw{s) of Record (attoch *=MParuod pope tO IfSt edditloliat t)rvnars . -
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LAMM Address
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city state 7jp C', �
10. Deed SO-Dk No 49 j �) state Zp
_ p fVo. �� 5 — Provide acopy of the n+o.t Offfent deed
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PWWWM trot of ((s) who am �y Mspansible for the land-draturb► g
"pOfte" p hOs on an attached shoot.) H the ac#rvity i Provide a
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� � �o or � rimy be k sbd as ft fmagcIapy� rs�spvns b4pw fy a Arm ,k a
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Currant Matllnp Address Cturmt Sheet Adcea—
LUA _am LS 6re- 0„
� sGrte � � see

Current Mailing ,address
•,-narra � / � �F
•-4leargnat ry
No Y Resp,rrntyabrA p F a,r N _
��'1S(e�ni' Y cg nrp a r"ralerft ��t3wr
rl.,- �` NRrth ��41rnp �ma
Currant �4_t_(�/s
Ent...d
Ma:lire gdaress
Cr --�5- , Curresnt Stt"t AdArwa� - -
-___- State
retO�p
�honFr --
_
- __ -- Fix Numtswr Z,rq
(b) Ff the pinoncrali - -- -- - -
as.9ilmod ni♦mR Y Re3pon:srble Ps►riy is a i'wrinr�rshi � -•� --- ..—
rs a Cor wttaeh ■ Copy
or the
Certificate
of r►a P or other PLXaErPn, Hamer, !"`e" wta®'n41 ,r, bus+Hess
and street ddHrrrss tst the •urrrW Nwmw, if [!ya t trtaru a"dAr an
RH9ryttergo Agent .�a1ty Reepp�s� p�,r
Name of Registered Agent
E-mad Addrm—
Durrent Street Address
ilp C7 ---
Telephone State -
- -- -- --- — Fax Nurnber
The above information is Erne and
correct to the best of fey knowledge and belief and was
by me under oath (This farm must be signed by the Financiau provided
Or his attorney -in -farm, or if not an individual by an officer, director Parts Responsible Person if an individual
the authority to execute instruments for the Financial! Responsible
or r istered
corrected information should there be an change y possible Pe agent with
y nge in the information provided herein. a to provide
IType 4orrin name ��
rtle Authority
Signature
- ___---�-� Date
-_ -
L State at m t�t�
a Notary Public of the County of
�! i�'
personally before me this day hereby certify thatC-45V-�r"
vy him. � being duly sworn acknowledged that the agave form was executed
Witness My hand and notarial seal, this
N
OTARY AB1THA CHARLES
3[1C . STATE OF U CW
n ohs Courly of j
My commission expires?