NCC233605_FRO Submitted_20231206

FINANCIAL RESPONSIBILITY/0 ERSHIP 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. Prel,ed NarRi. - 2-V6-'14" ' &JtJ5
2. Lecatir!I 4 iend-distu,.alrtgn vtyCounty mra, mrcrd-igaimhip
C Latilludk Si-• Ungltuda 'ThE5 b91(tor-÷7:)
61:,porakaate data land4sWid3inv actiV*CYM©7:NFIRilr,24,!, OV
IP 4. Purpose of development(residential,commercial, industrial, institutional, etc.): • /
5. Total acreage disturbed or uncovered (including off-aite boffolv and waste areas):
6. Amount of fee enclosed: $ 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 b n filed? Yes No Enclosed cJ
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
NameLksWx- • _ E-mail Address .D ice ac"eliaprnentrf &6'n
Telephone Cell# I 109
9. Landowner(s)of Record(attach accompanied page to list additional owners):
Ace_ pe ve__( t ter42 eVV7 u' Wi 7 1 o 13
Name Telephone Fax Number
//‘ 'r r-kr+DP (:).2) Rci ete/
Current Mailing Addrd-ss Current Street Address
1\-)C- 63// L (r‘ iNer\ (-1)3 S-TeD
City State Zip City State Zip
10. Deed Book No. C\ck Page No. a (.0 *R-- 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
comprahcile;n. TA of all responsible oc-glies on an attached sheet.)If the company or firm is a sole proprietorship,
the nem,oP,to.crJeworraFimni rAF27 ,','82ed as the financially responsible parti:
/77Ptcecle%-e-1491ery rrt,r p
E-mail Address
rsp br) Pr-t Y)s Pe/
CALirrc-nt NallIng Address- ( Cffranl.Waal AdLIFesa
cf\ N,,C '2,1_53 -1L L4: L110 w3- 017g)
Zip CAty StateZip
Telephone Fax NtarGber

2. a) rgir. V� i gnu �- sp nsiN''I Party�, R., �'€. nth rt of Non,. Fan a `�p� name
d ' c'�ot address
��,� p, the � e��.:rt��,���oJ �������a �io��t Party.�� s6..�-��. �' ;�:.��,us ., �v� .,�� �,,,�,��.:;ao��� �u✓� ,n�'l�u�� �(� `�ir�+�, �I�1�l�
of yiv2 designated J North t4 CS `IM E,l !o
Name d ?i Ai re
Current t aiii g Address Current Street Address
City Stab Zip City State '§
Tei-phone Fax Munior_
(b) It the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, aEach a copy of `,110 ©ernle to of Assumed Mame. if the Fin ncialiy Responsible
Party is e Corporation,give name and street address of the Registered Agent:
Ma me ot R aa d k ; 3 A E-Mail Address
Current i iaiiing Address Current,Street Address
State Zip City State Zip
1eieptaon T__ Fax Nur aw
The bcve information is true and correct to the best of my knowledge and belief and was provided
by. me under sib cr e form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the euthoo ity to ear cute instruments for the Finenci iiy Responsible Person). l agree t.* provide
rrectted irtf k n ould there be any change in the information provided herein.
or print name 'aft cab Auth
c gr-attire Date
ie. m- S S , a Notary Public of the County of V lG im _ -
State of North Carolina, hereby certify that `.d►n .-k%' x Ac.ty to appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,this O� day o , 20 93
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�assre
�a i �OMINls •
/��. rypR ) - -___
N o rt 0 s. Notary en
Sea
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