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HomeMy WebLinkAboutNCC241467_FRO Submitted_20240514 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. (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 tic*JA VECC gar PO Ai Ici/ — pa.2. 2. Location of land-disturbing activity: County W4 hUrt,4 City or Township Highway/Street ber/ 12D Latitude' 29 12 4 M Longitude or j _! 3S:ji 3. Approximate date land-disturbing activity will commence: A' o 2 4. Purpose of development(residential, commercial, industrial, institutional, etc.): gairFlIDAL- 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): /5:7S- 6. Amount of fee enclosed: $ 4}L�• °® . The application fee of$150.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$1350). 7. Has an erosion and sediment control plan been filed? Yes / No Enclosed 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name 7)EV2Ek SL alAA 4A/ E-mail Address 7) E/ t3 Al EZ4,066" tt Telephone Cell# spa-s 07` 89/p Fax# 9. Landowner(s) of Record (attach accompanied page to list additional owners): 1(47"& MA/b /1 cvA/fg 44.4. `8o_'f4'4- c Name Telephone Fax Number Current Mailing Address Current Street Address ptia),E6Mar NC Zbl/7 City State Zip City State Zip 10. Deed Book No. Page No. 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. t/ /O- /A t1O > 'Y7y/1/ ea ,z,'r- e EUVI 7t--/AUpC ktjo 444'1 Name E-mail Address / W/LuAMON/ 1 SrE- 207 Current Mailing Address Current Street Address AlopErt/f AK, 20117 City State Zip City State Zip Telephone 733U'44fq- 2'1 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: 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: 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. D?fi Wie L NAlatoere Type or print name Title or Authority ri Signature Date g. GA/ ''1)�,00, , a NotaryPublic of the Countyof rJ l� Aft/ �t r� � State of Pd �r�a, hereby certify that i1 lai/ ' 10" We'(( 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 04, i day of YLI , 20 ot`t 4Nota VOL 66(AU(41°7 Seal My commission expires Anne B.Gardner Notary Public,Alabama State At Large My Commission Expires 2-15-2026