NCC220763_FRO Submitted_20220224

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 Duality Submit the completed form to the appropriate
Regional Office. (Please type or pnnt 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
2. Location of land -disturbing activity: County it a- City or Township 7� r� _
Highway/Street kf'bzC"--} �cl Latitude 35,7&T(-) Longitude
3- Approximate date land -disturbing activity will commence:_ '� - I � r 'J C
4 Purpose of development (residential, commercial, industrial, institutional, etc.): f�c�ca1 0.i
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): -j + SG
6. Amount of fee enclosed $ q o The application fee of $100-00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900)
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 Ui kISL2+\ `ti' C'.-k-{ 5 E-mail Address f q� It ou 4�65 q Yiti
�1 .r—
Telephone f Iq- 4 - G73cj Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Telephone
Current Mailing Address Current Street Address
414
Fax Number
City State Zip City State Zip
i
10. Deed Book Na. �__AU` --YC 1 Page No. Qa (-�glL Provide a copy of the most current deed.
Part B.
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.
r�evA� lU(cLL 2 1C S2•rr�� U 5 G ft'lat1 , Gorh
Name E-mail Addr s
Current Mailing Address Current Street Address
I t'' � 0- 2750,7- & k 7 v
City State Zip City State Zip

Telephone �31 9i 2- -0773 Fax Number f
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
/V �
Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
(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. gnre name and street address of the Registered Agent
Name of R gistered Agent
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
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 -fad, 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.
Type pr pnnt n,�kne Title or Authority
Z-- zz
Date
I, / �rG Q N , a Notary Public of the County of
State of North Carolina, hereby certify that PY'1 C` h appeared
personally before me this day and being duly swom acknowledged that the above form was executed
by him
Witness rrW4qt
TV9r4 notarial seal
TAR
�e�f4 G
N
this day of �ru�` 20
Notary
My commission expires