NCC240406_FRO Submitted_20240213

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 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. ATMC Pender
1. Project Name
2. Location of land-disturbing activity: County Pender City or Township Burgaw
Highway/Street NC Hwy 53 Latitude 34 32' 37" Longlfuci,77 57' 10"
3. Approximate date land-disturbing activity will commence upon receipt of permits
4. Purpose of development (residential, commercial, industrial, institutional, etc ):commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 3.2
6. Amount of fee enclosed: S 400 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 X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Daniel Tharp E-mail Address [e-mail]
Telephone [phone] Cell # Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Atlantic Telephone Membership Corp. 910-775-1665
Name Telephone Fax Number
PO Box 3198 640 Whiteville Rd NW
Current Mailing Address Current Street Address
Shallotte, NC 28459 Shallotte, NC 28470
City State Zip City State Zip
10. Deed Book No 4743 Page No. 201 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.
Atlantic Telephone'Membership Corp. [e-mail]
Name E-mail Address
PO Box 3198 640 Whiteville Rd NW
Current Mailing Address Current Street Address
Shallotte, NC 28459 Shallotte, NC 28470
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
N/A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
Clint J. Berry Vice President
Type or print name Title or Authority
q � r'
Signature Dat(frA
I, T,(1{1 C. -gavel , a Notary Public of the County of Peat {
State of North Carolina, hereby certify that (_Lb?I- J 6.e/ appeared
personally before me this day and being duly sworn ackr wledged that the above form was
executed by him.
Witness my hand and no`agailemp44this day of J a/l,ri , 20L-
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/ )Pi///A (?,
Notar
Seal t.
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