NCC230017_FRO Submitted_20230106

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name4580 White Level Road Erosion Control Plan
Z Location of land -disturbing activity: County Alamance City or Township Mebane
White Level Road/SR 1917 36.1249-79.2792
Highway/Street Latltude�decima� degreesy LOngltude�decima� degrees]
3. Approximate date land -disturbing activity will commence: November 11 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas). 3.0 acres
6. Amount of fee enclosed: $300.00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900)
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed p No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ryan Webb E-mail Address [e-mail]
Phone: Office # [phone] Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Justin & Michelle Gibson [phone]
Name Phone: Office #
1609 Apple Street
Current Mailing Address
Metarie LA 70001
10.
Current Street Address
City State Zip City
Deed Book No.4346 Page No.990 992
State
Mobile #
Zip
Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Justin & Michelle Gibson [e-mail]
Company Name E-mail Address
1609 Apple Street
Current Mailing Address Current Street Address
Metarie, LA 70001
City State Zip City State Zip
Phone: Office # [phone] Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
Ryan Webb, MTM Construction
Name of Registered Agent E-mail Address
164 Solstice Drive
Current Mailing Address Current Street Address
Haw River NC 27258
City State Zip City State Zip
Phone: Office # [phone] Mobile #
Ryan Webb
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Ryan Webb Agent to Owner
Type or print name Title or Authority
la/. _
ure Date
I, SUZQnrIG�Ylp�naS50fr1 a Notary Public of the County of
State of North Carolina, hereby certify that 'Ryan Wcbb appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 31 day of 06i'DW 20 Z Z
Notar
Seal
My commission expires 12' d�' 2622
SUZANNE M THGMASSON
NOTARY PUBLIC
GUILFORD COUNTY, NC
MyCWffA a,fi*1 11- o , - 7011-

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed
Landowner 4 of Record:
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
City
Deed Book No,
Landowner 5 of Record:
Name
Current Mailing Address
City
Deed Book No.
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
Company 2 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 3 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Company 4 Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City
Phone: Office # Mobile #
Company 5 Name
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Phone: Office # Mobile #
State Zip
State Zip

We, Justin and Michelle Gibson, owners of the property located at 4580 White Level Road,
Mebane, NC have hired Ryan Webb and Sara Thompson aka MTM Construction and Design,
LLC, as operating agents, to work with architectural and structural engineers to make decisions
as well as submission of any permitting paperwork with local authorities. We also hereby
acknowledge that MTM Construction and Design LLC(agent of this property) have agreed to
take on full liability and responsibility for architectural and financial items for said property
renovations.
4ni
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Date
Michelle Gibson Da