NCC233593_FRO Submitted_20231206

FINANCIAL RESPONSIBIUTY/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 and/
or fax information unavailable,place N/A in the blank.)
Part A. {�,
1. Project Name ( e kyrO + sue ,~ ot+ €1 r`t s lzr+
2. Location of land-disturbing activity: County C um ktiSlorrk City or Township Li r..r t
Highway/Street 5-6.1774 - C.Y Latitude a 7-147'(D IC1 Longitude —9-5 •f>13(a'-Et)
3. Approximate date land-disturbing activity will commence: 6,)AA) 2— 4 `c" '' "7 o"z _ _--
4. Purpose of development(residential,commercial,industrial,institutional,etc.): Po4,;6eyth I
5. Total acreage disturbed or uncovered(including off site borrow and waste areas): • 7 Z 14c r c.
6. Amount of fee enclosed: $ l 0 0 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac=$900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed J t'q`
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name;..,)1 r' N-e-N.Ae...44:4E-mail Address "Z- 0 q-ce AGA.e.topolercIorfxcaa+n
Telephone Cell# q i 0 P? r 2.-a fax#
9. Landowner(s)of Record(attach accompanied page to list additional owners):
A-c. (.mac fi rfi Oyer '9 ' 1 ! b /3
Name l Telephone nn Fax Number
Current Mailing Add Current Street Address
fNev-. 1 C-- Z Y)3l/ t (r �e�r. tQc.-- 2�3
City State Zip City State Zip
10. Deed Book No.9 Page No. a Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
15w12 Prtt.c ' e.*too*rr 3 r p. yam
NameE-mail Address
rttct gafvytkey L.D.e)tc-7 Altyrtpel
Current Mailing Address f Current Street Address
L!t Ace RC_ 2 th3cr6 L 'v' r. 2 ilt3J
City State Zip City State Zip
Telephone Qt c o 1-2-6 7- Fax Number__

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and stef'-,
of the designated North Carolina Agent:NOTIO E-mall Adansse
Current Mailing Address Cr011u.7.353a Steet Address
C4' Sfige Zip Clt9 State Zip
7-Tag
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, teach a copy (e.f he CerMcate of Assmmed fla,, c. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
N").:TLS CA' ,a-,7,1s1,Tro,, P,gmt a'-',- ail Address
---
C;',_] vest Address
City Slats Zip City Stat.: Zip
Teiephone Fax Number _
The above information is true and correct to the best of my knowledge and belief and was provided
by me u-der oath (This form must be signed by the Financially Responsible Person if an individual
r his att.:rney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authevity to vcaculte instruments for the Financially Responsible Perstn). I agree t , provide
etaiYad hi7WAIErutil Ohatild ft:1.)re, be any change in the information provided heroin.
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Tale er Autirrity6V-
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SA-attire Date
a Notary Public lf the County of r ..._
State of North Carolina, hereby certify that A C.A. appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
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Witness my hand and notarial seal, this R.6 day of 0 CAA , 203
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