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Home My WebLink AboutNCC232555_FRO Submitted_20230829 ' Check J this project/oARfA+funued O 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, including any activity under a common plan of development of this size as ommynad by the NCGO1 pemmit, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Land C>uo|ib/ 3ection, N.C. Department of Environmental Quality. Submit the oonnp{abad 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 b|anh.) Part A. ��A �(��J ��|�� 1. P��ectNome��" ^"v~^~~^" RIDGE project involves American Rescue Plan Act (4RFA) funds, list the Project Name below under which you applied for funding through the Division o/Water Infrastructure(DWI). /��J�� VV 2. Location of land-disturbing ec�ivity: Counh/~~'�~~`-~�"" City or Township STUMP S[][]N[l &J�� 1 �O-� 34V8280� -774922e0 HiQhw�y/Q�reat'~~^^~^ ~ " ^^^' Lati�udeweu�° m�°a* � Longbudew°mm*o"u"m* � � �� A�� 3. Approximate date land-disturbing activity will con�mence:"-- `=-°-""-^^ ��F��hJT|�| 4. Purpose ofdeve|opnment(nauidenUo|. 00nonnevcia[ induatriaLinat�uUonoisdoj: ^ ~�-`�^^�^-"� ' "" ^`- � � 5. Total acreage disturbed or uncovered (including off-site borrow and vvmetaonemm):~-^=- �� MO G. Amnountof fee enclosed: $~"°"'~'^^ . The application fee of$1UO.OU per acre(rounded upto the next acre) io assessed without m ceiling amount (Exnnmp|e: 8.1O-oona application fee io$SOO). Checks should be addressed toNCDEQ. 7. Has en erosion and sediment control plan been filed? Yes(g] Enclosed E3 No 0 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: �/�A�J | ��y��~� ��TT��1� ��J�� (�yN Nonnm=~~' "^` L. PIERCE^~�°- E-mailAddraea`~`- ' ^ ` ^�x��=^-^ `"~^'~�~~'"' {��O_��_��Mn ��M �� l1� Phone: Office � ^= =-'= �""� Mobile � `�-=`^�-�" '~^ Q. Landowner(s) of Record (attach accompanied page to list additional owners): DIVERSIFIED INVESTORS, INC. 910_346-9800 Name Phone: 0fhma# Mobile# PO BOX 1685 405 ]OAKJSMN B1 VD Current Mailing Address Current Street Address JACKSONVU| | E, NC 28541 JACKSOhJVI| ! E, NC 28540 City State Zip city State Zip 10. Deed Book 5831 7'1 5 Provide a copy of the mo I st 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 poge.) ff the company isa sole proprietorship urif/h*landowmor(s)is an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies). DIVERSIFIED INVESTORS, INC. BETTYB@|| PK]C_COyN Company Name E-mail Address P/� �<�� R� ]/�A��|�� | �yFl _ _ -' - . __- .~~ �.~. . ..~.... `~^-, ��' Current Mailing Address Current Street Address JACKS/�N��U | E yJ�� 1 ]��/��VU | � �� ' ��- -' -_. __ _. _ _ ____. . __~ ~.~.~ .~ city State Zip City State Zip �1O��MO Phone: Offioe# � '""-�^~"^^"" 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: Beft\f Bullock F»etf\/b@j|pnc_co[O Name ofRegistered Agent E-mail Address P.O. Box 1685 485 Johnson Blvd. Current Mailing Address Current Street Address Jacksonville NC 28541 Jacksonville NC 28541 City State 3]p city State Zip /C�1O\ �z1��-�Ay�B Phone: O��oe# \� '°/ °-'`^ ��"" Mobile# Name of Individual to Contact(if Registered Agent isacompany) (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: Offiva# K8obi|a# Name of Individual hm 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 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. Betty Bullock President Typ print Title or Authority i l jl/I'f23 Signat re Date I, 'Oe5\`f Q Q, cz. 1' levy ..Q_- , a Notary Public of the County of O1\' ou.J State of North Carolina, hereby certify that X-1 Stia\\o 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 19-1"day of —SOY) , 20 23 `0 la PIS►Jl'1,, Tthirt.O.S Q_,. 6,-,-,,,,a, ,{� Notary W f' �KARY U� o • ��, z` My commission expires /O1ZL}l 7o2�.Q 0w Cd , ^ Continued from Items B & YD in Part of the Financial ResponsibilitylOwnership Form for multiple owners. Attach copiesnf this page eo needed bzlist all landowners. Landowner 2ofRecord: marno Phone: Of5oe# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy qf the most current deed. Landowner 3ofRecord: Name Phone: Ofhoe# 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 4ofRecord: monma Phone: Offioa# yWobi|o# 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 GofRecord: Nome Phone: Dfhua# Mobile# Current Mailing Address Current Street Address Oih/ State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. . . ' Continued from Item Yin Part Bof the Financial ResponsibilitylOwnership Form for multiple Attach copies of this page aaneeded to list all financially responsible parties. Company 2Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Company 3Name E-mail Address Current Mailing Address Current Street Address ` City State Zip City State Zip Phone: Office# K8obiie# Company 4Name E-mail Address Current Mailing Address Current Street Address City State Zip city State Zip Phone: Offime# Mobile# Company 5Name E-mail Address Current Mailing Address Current Street Address city 8bde Zip City Gbda Zip Phone: Office# KAobi/a#