HomeMy WebLinkAboutNCC230619_FRO Submitted_20230310FINANCIAL 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 Name Rain for Rent T
2.
3.
4.
5.
Location of land -disturbing activity: County JohnSton City or TownshipFour Oaks
Highway/Street 4545 US Hwy 301 Latitude(decimal degrees) 35.45740 Long itude(deamal degrees)-78.39215
Approximate date land -disturbing activity will commence: Winter 2022/2023
Purpose of development (residential, commercial, industrial, institutional, etc.):.Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.1
6. Amount of fee enclosed: $ 700.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William Frank Lee Sr. E-mail Address will iamslynChv@gmail.Com
Phone: Office # 919-934-2700 Mobile # 919-631-9005
9. Landowner(s) of Record (attach accompanied page to list additional owners):
William Frank Lee Sr. 919-934-2700
Name
P.O. Box 148
Current Mailing Address
Smithfield NC
Phone: Office #
919-631-9005
Mobile #
1305 Brightleaf Blvd., Ste. 104
Current Street Address
27577 Smithfield NC
City State Zip City
State
27577
Zip
10. Deed Book No. 6350 Page No. 121 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 or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
William Frank Lee Sr.
Company Name
P.O. Box 148
Current Mailing Address
Smithfield NC 27577
williamslynchv@gmail.com
E-mail Address
1305 S. Brightleaf Blvd., Ste. 104
Current Street Address
Smithfield NC 27577
City State Zip City State
Phone: Office # 919-934-2700 Mobile # 919-631-9005
Zip
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:
N/A
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)
(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:
N/A
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.
N/A
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.
William Frank Lee Sr.
Type or print name /
ignature
Owner
Title or Authority
Z) 'r— C el - 4V
Date
-,a Notary Public of the County of J n h 4j � ,61 �
State of North Carolina, hereby certify that 1�, n t, `� �A+� 1�, L� E.,r . 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 sea[, this I L day of ],.>e 20
\0\11IIIf/////
R/y0 %� k�� ale_.
Nota
= N ed•3A R
My commission expires
PUBLIC 0:
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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:
N/A
Name Phone: Office # Mobile #
Current Mailing Address
City
Deed Book No.
Landowner 3 of Record:
N/A
Name
Current Mailing Address
City
Deed Book No.
Landowner 4 of Record:
N/A
Name
Current Mailing Address
Current Street Address
State Zip City
Page No.
State Zip
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.
Phone: Office # Mobile #
Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
N/A
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.
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.
N/A
Company 2 Name E-mail Address
Current Mailing Address Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
N/A
Company 3 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
N/A
Company 4 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office #
Mobile #
N/A
Company 5 Name
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip
City
State
Zip
Phone: Office#
Mobile #