NCC230180_FRO Submitted_20230123

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 NIA in the blank.)
Part A.
1. Project Name mot*- ($ 5
2. Location of land -disturbing activity: County G. mWchrZ City or Township
Highway/Street S - C-T Latitude(dedma[dagmasi- a`f:v-oLongitude(docimardegrBes) --4$' i�3 C,
3. Approximate date land -disturbing activity will commence: C)Ckvi (--`H'r Z�
4. Purpose of development (residential, commercial, industrial, institutional, etc.):KeS�r�q
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3- cb
6. Amount of fee enclosed I L402 ' — _71 • The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 peracre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900). Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed M No ❑
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
E-mail Address C1C��ve m �0 1�ie f D
NaD q L1
Phone: Office # Mobile # �} t oD + Z(I �J
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C
Name CPO CC__ g_A_
Current Mailing A ress
e-1y �� r�C-
City State Zip
� r
P��
hone: Office # Mobile #
Current Street Address
2 � � �
City State
z
�p
c� 5-9 Page No. Provide a co
10. Deed Book No. 1 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 or if the fandowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
ve LAC, � •� �o rr�n�
0'�'�` C�tnM�
c, t c alit
Company Name E-mail Address CUJ
�2gV'4;,-„,,5a 4 "(rG
Current Mailihoddress
e-Cvtl W,� Z�3I1
City State Zip
Phone: Office #
Current Street Address
- Ar-Ne r-, vJ(2- >3 Vo
City State Zip
Mobile # (0 itfl 12C
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
alnd arty iit addomestiess the Regi registe ed on the NC Secretary of State
business registry, g t
E-mail Address
Name of Registered Agent ✓ r� i A `
Current Street Addres
Current Mailing A ss
IVG z� e ,�rl� ► Z�31�
f State Zip City State zip
'City
Phone: office #
Mobile # t 9 (
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
Current Msiling Address
Stag Zip
City
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
State zip
Name of Individual to Contact (if Reg
islered Agent is a company)
Responsible Party is engaging in business under an assumed name, give name under
(c} ]f the Financially which the companyBusiness As. If the Financially Responsible Party is an individual, General
es
is Doing

Continued from Item 9 in Part B of the Financial Responsibility/Ownership Fonrr for multiple parties.
Attach copies of this page as needed to fist all financially responsible parties.
Company 2 Name
Current Mailing Address
City State
Phone: Office #
E-mail Address
Current Street Address
Zip City State Zip
Mobile #
Company 3 Name E-mail Address
Current Mailing Address
Current Street Address
City
State Zip City State Zip
Phone: Office #
Mobile #
E-mail Address
Company 4 Name
Current Mailing Address
Current Street Address
City
State zip City State Zip
Mobile #
Phone: Office #
Company 5 Name
E-mail Address
CuMailing Address
Current Street Address
rrent
Cit State Zip City State p
y zi
Mobile #
Phone: Office #

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.
Landowner 2 of Record,
Name
Current Mailing Address
City
Deed Book No
Landowner 3 of Record:
Name
Current Mailing Address
City
Deed Book No
Phone: Office # Mobile #
Current Street Address
State Zip City State Zip
Page No. Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
State Zip City State zip
Page No. Provide a copy of the most current deed.
Landowner of Record:
Phone: Office # Mobile #
Name
Current Street Address
Current Mailing Address
State
Zip
City State Zip
City
Deed Book No.
Page No.
Provide a Copy of the most current deed.
Landowner 5 of Record:
: O
Phonefce #
Name
Mobile-4
Current Mailing Address
Current Street Address
State
Zip
City
State Zip
City
Deed Book No--------'
Page No.
Provide a COPY of the most current deed.

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
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
�.i�+• �1utiV1 rr Ccsrisd"�' b 1 0 q 0 � •`AYYI
Engineering firm or other cons nt E-mail Address
[a{v1YA c� tJ 2z009-2- q `0 66Tvz>Zx, l
e or print Phone: Office # Mobile #
Individual contact person (type }
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 individuals)
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 changelan tall Resp Responsible
pro art herI agree to provide
corrected information should there be any
Title or A t r'
ype or print name
I f L-2"--r-3
1 Dat
a Notary Public of the County of bCr f C -A
State of North Carolina, hereby certify that �orta�t,.� �ttp�Co 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 day of �&' � , 20 �) 3
H I f IF If 0"'p.
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Seal:o�0'(ARY�"'
,G�J ebrUary
AND CC,••�•.
Notary
My commission expires O-_ a0 a I