NCC230981_FRO Submitted_20230405

FINANCIAL RESPONSIBILITY/OWNERSHIP P®R
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 V1 (n� �( U6 u
i
2. Location of land-disturbing activity: County �A l e City or Township 6 `
Highway/Streett Latitude(dechai degrees) Longltude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 10/3( /27-
4. o '(�
^ Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): . 66
6. Amount of fee enclosed: $ too 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 ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name ` 'I,v1t l�f
W �' E-mail Address ��� l �� �1p
Phone: Office# c5q-t2(t Mobile# 3�6 �11d2
9. Landowner(s) of Record (attach accompanied page to list additional owners):
( - s V&' 66T1 _�2-It 336®'34 - TWE
Name Phone: Office# Mobile#
WI 27f03 mpqi(irt�
Current Maflirih Address Current Street Address
WIt-J �� �C 27c s MAI,
City State Zip City State J Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.

i
Part Bo i
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list '
of all responsible pasties 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).
LL v) I C
'Company Name E-mail Ad r ss
e
Current MallirA Address Current Street Address
City State Zip City State Zip
Phone: Office p 65 ZtT— Mobile# roQo2
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 aqd 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
usiness 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 FinAciaily Responsible Party is not a resident of North Carolina, give name and street address
of 'he 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 ResponsibleParty 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 t[US 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, orif not 8D individual, by an officer, director, partDe[. or registered agent with
the authority to execute iDotrUDlSDtS for the FiO8Doi8Uy Responsible Party). | agree to provide
Cn[Rao8ad information should there be any change in the information provided herein.
Signature Date
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!. U @ Notary Public nfthe County of
Gt8teofNO�h <�aro|iDa, hH[ebySg�ifvth8t ppeaFedperSODGUy
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
�x
VVitnoSS my hand and OOt8rie| seal, this —�_��A ___dGy of/ C~-h���� . 2 '
Notar
�e u rJ/+/�� ` \
- �� My oO[n[niSsion expires lao a-c-z'