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Home My WebLink AboutNCC230976_FRO Submitted_20230405 / ro"'�� Check if this project isARFA-fumdod [771 FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land-disturbing activity on one or more acres ascovered bv the Act, including any activity under a common plan of development of this size as covered by the NCGO1 permit, before this fnnn and en acceptable erosion and sedimentation control plan have been completed and approved by the Land Quality Seotion, 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 ie unavailable, place N/A in the b|ank.) Part A. ��UTA��T��hJ ��/��~��T� 1� �rujectNam ^^�^^� ' ' "^-^`�� ' �-' ~'� CONCRETE �- *Ifbh/s project /nvn/w*o American F7eaouo Plan Act (4RPA) funds, //ot the Project Name ba/om/ under which you applied funding through the Division nf Water Infrastructure (DWI). ' (��U�|[] F��TT�V�� 2. Location of land-disturbing activity: County ^^ city orTownship CORPORATION DRIVE �4_04�� - 1 / Highway/Street Ladtudememmo/uvo�eu� LonQitudamuo'ma/ueo�ea '--- -�0 / ' ��880____-_- | Z��K�|| �� | 3. Approximate date land-disturbing activity will commence:^~' n x'`- "~`�^�~/ | |;J[�U�T��|�/ ! 4. PurpoaeVfdeveopn�ant (reuidenda[ nommen�a|. indua�ia[ inaMb�iona[ eb�)� '/��^^�� ' / m`^^- � /1� | 5. Total acreage d��/rbedor uncovered (including of�oheborrow and waste ereaa). ~^--rc~ � 6. An�ountof fee enclosed: ^^0O ° The application fee of$100,O8 per acre (rounded | upto the next acre) ia assessed without m ceiling amount (Examp|e: 8.1D-anre application fee ie$8OU). | / Checks should be addressed h» NCOEC\. � 7. Has mn erosion and sediment control plan been filed? Yes F] Enclosed No [] ! 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: | Nom / ARRY W. ANFlERSON E-mail Address andensonengineuhngpo@gmoi|.00m | C�1O-��r1_��M ��1/l_��[��_��(l� | Phone: Office � , " "^ ' �~^�^� Mobile � '� °"� "-""" Q. Landowner(s) of Record (attach accompanied page to list additional owners): J.H.M. INVESTMENTS 910-671-1964 910-734-8880 Name Phone: Office# YNobi|e# ��/� ��y�� /1�� 1 1� A��' �� o�T . .~ �~~~. . ^ .~_~ = . ." . .,, " ' ^� �_^^^� . Current Mailing Address Current Street Address | A UD��%��T-��hJ V�� Q | U8��T��U� hJ�� —~~~~��^-' ~ ' ~~' ^, ^ ~^~ ^-~~^~`~~ ^-`�`"^^°^-' ^ . ~°. ., . �� "_w^^°~^ city State zip City State Zip � 10. Deed Book No 11654 PaoeNo382_~385 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.) ff the company is a sole proprietorship orif the landommmns/is an/nd/uidua/kV' the nam*(s)of the ownar(s)may bo listed eo the finenna0yresponsible perty(ies). |�NY�� MUSSEL WHITE jamie.seco@gmaii.com �� '| ",^.".^-�� .".~��^�^-^_"". .. . ^_ |��0|��'��6B��(�v��O�0��U-c000 Company Name E-mail Address �� 1 �� " �� '� ' ~~ `~^~^^ ' '^-`� ^~ ' "^^ ^ """ / ^ =- �� ' Current Mailing Address Current Street Address LUMBER TON,. ~~. ., . .~. ._~~`^"`, LUMBER TON,O.~, NC 28358 City State zip City State Zip �1�_��1-�0�� 1M_��-��M Phone.- O�oe# � ' ° �^ ' "�=` �obi|e# � ^" ' =� ^~^^"� Note: If the Financially Responsible Party is not the owner ofthe 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 oonbn| plan and to conduct the anticipated land disturbing activity. 2. (m) 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: 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 tn Contact(if Registered Agent ieacompany) (b) If the Financially Responsible Party is not resident nfNorth Cono|ino, 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: Offiue# YNobi|e# Name nf Individual 0o Contact(if Registered Agent iaacompany) (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 in an individual, General Partnership, or other company not registered and doing business under an assumed name, attach a copy of the Certificate mf Assumed Name. Company DBA Name The above information is true and correct tOthe best of my knowledge and belief and was provided bV [De under oath. (This form must be signed by the Financially Responsible Person if@niDdixidVa|/s\ or his attorney-in-fact, or if not an individual, by an VffiCer, director, partner, or registered agent with the authority to execute iOst[U0eDLS for the Financially Responsible Party). | agree to provide CO[[8Cted iOfo[nl8ti0O should there be any change iO the information provided herein. A�0�� M�� K�� VHN|lF� ��[�� ^,��xvnu_�� nv"��-c_vv/ �/ " �_ nv/�_�x"��_u ^ Type,or print name Title or Authority Signature Date ---------------------------------------------------------------------- k L a Notary Public of the County of | State Of North Carolina, hereby certify that appeared personally | before me this day and being duly sworn ackri-owledged that the above form'was executed by him/her. | � VV�neGSUly hand and nOt@h@| Se@|' this day � -�~�--~ R. Notary u " | Seal | ~ 'M 6 Expires My commission expires ^^L. ' .��" Cu"�0` / | � � | |