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North Carolina
Department of Environment and Natural Resources
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Division of Waste Management
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r r MichAei F, Easley, Governor
? r Waant, G. Ross Jr., Secretary
�r Dexter Matthews, Director
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NCDENR
LAND CLEARING AND INERT DEBRIS LANDFILL NOTIFICATION
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Pursriant to 15A NCAC 133 .0563(2)(a), the land owner(s) and operator(s) of any Land Clearing and Inert
r Debris Landfill under two (2) acres in size shall submit this notification form to the Division prior to constructing
ti 1\ f oreope[ating the landfill. This form must be filed for recordation in the Register of Deeds' Office. The Register
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oy Dged -rh"Il index the notmcat on under the name of the owners) of the land in the county or counties in
Which the Iced is located. The Register's seal and the date, book, and page number of recording must be
included on this form when submitted to the Division. This notification is not valid to authorize operation of
sir a landfill unless complete, accurate, recorded, and submitted to the Division as required by 15A NCAC
13a .0563(2)(by- �
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f1. Fs6ifty Name: VA rxL �t—i �r L nt,,L'► �� _ _-.
2. f acilly Iocati?n (street address): t O �A n k\OW V r
City-• Yalu 2tf-- u:p Ick County:_ O&I r &X, Zip: -7 79 70
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3�•. Dj,`ections tci Site: -rarV off �e Q
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The 11b,
doh which tl�N landfill is located is described in the deed recorded in:
o 0. I page: =-,�Z 6 t county:
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Name of Ind owner: I - � aV E . % L t r—
Mailing address of land owne : _ , 'o (0- es r�rt
City: i ttate:JV CI Zip: 27 f3-70
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Telephone ni;nberof land owner:{
If the land is owrierby r Are thAn one pers6rL-a0ch &1ditional sheets with the name, address, and
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phone number of all additional land owners. ti 11
Name of operator:
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Trade or business name pf operator: C_yyi,, V /(n �o0� C-cws True--kpu
Mailing address of operator: �p 4-I C h 1D �1; QP-AS ^1-ra.-l__
City. D O f State._ • �, -f r 'Z.ip 7 S 7o
Telephone number of operator:
If the landfill is operated by more thin one person; Wt cti additional �heets with the name, address,
and phone number of all additional operators.: '•�
Projected use of land after completion'bf landfill operations: F✓ c>
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Doc ID: 002531590005 Type: CRP
�,� a,(p ' •• J Recorded: 06IA212008 at 002:29 AM
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fit Judy Evans-8arpee Repist'r of Deeds
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Book 2244 Pacgeti- 126 Seq- 1

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000X 244 PA6E727
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rr Certification by Land Owner.
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1rr I ceritfy that the information provided by me in this notification is true, accurate, and complete to the best of
r my knowledge. The facility siting and disposal operations of this Land Clearing & Inert Debris landfill will
comply with the requirements of Sections .0563, .0564 and .0560 of 15A NCAC 1313, North Carolina Solid
Waste Ilr4anagement Rules. The facility and operations of this landfill will also comply with all applicable
federat, State, and Local laws, rules, regulations, and ordinances. Where the operator is different from the
\ f landf !mwr�r, I, the land owner, have knowledge of the operator's plans to dispose of solid waste on the land
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and I s6ecifi`cally grant permission for the operation of the landfill. I understand that both the land owner and
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9perator are jointly and severally liable for improper operations and proper closure of the landfill as provided
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J for by'North Carolina General Statute 130A 309.27. I further understand that North Carolina General Statute
13OA-22 provides for Ndministrative penalties of up to fifteen thousand dollars ($16,000.00) per day per each
violation of 6.he Solid VVaste Management Rules. I further understand that the Solid Waste Management
Rules mayrbe revised ofi amended in the future and that the facility siting and operations of this landfill will be
required go comply with,�ail such revisions r amendments.
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Print Namq (Owner] k Signature (Owner) Date
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North Carolina'—' Z
County..
�4.1G'c� .'.� r � T� rr ' f , a N tary aublic for said County and State, do hereby certify
That. t'jC."+ey-77�Nl - personally appeared before me this day and acknowledged
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the due execution of the foi,&Deoinq Kstrurfient. �� r
and and official sea}, this the day of 1 20
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Notalry'public ti 1
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My commission expires J� - 20,�
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Book 2244 Pacgeti- 126 Seq- 2

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BDGX2244 PAGE728
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I certifylthat the information provided by me in this notification is true, accurate, and complete to the best of
i r my -knowledge. The facility siting and disposal operations of this Land Clearing & Inert Debris landfill will
cor'nply with the requirements of Sections .0563, .0564 and .0566 of 15A NCAC 13B, North Carolina Solid
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�aster f anagement Rules. The facility and operations of this landfill will also comply with all applicable
Federal, State, and Local laws, rules, regulations, and ordinances. Where the operator is different from the
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f' lanA owner, I, the land owner, have knowledge of the operator's plans to dispose of solid waste on the land
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and I ispe'ei ally grant permission for the operation of the landfill. I understand that both the land owner and
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.operator are jointly and severally liable for improper operations and proper closure of the landfill as provided
s for Vy North C�roiina General Statute 130A-309.27. I further understand that North Carolina General Statute
136A-22 provides fir administrative penalties of up to fifteen thousand dollars ($15,000.00) per day per each
violation or the Solid'. Waste Management Rules. I further understand that the Solid Waste Management
Rules may be.revisedlor amended in the future and that the facility siting and operations of this landfill will be
'rgquired to go:mply with all such revisions or amendments.
Print Name {Owe Signature (Owner) Date
P.
North Carohr%--e I I R Z
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Cdunty
l 1 r�latan Public for said Countyand State, do hereby certify
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That - UkQF ?� pOrsonally appeared before me this day and acknowledged
the due execution of the foregoincf.4nstrt ment. r— �
Witness my hand and official seal. this the �_ day of k 2pQ—S .
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Notary Public .1
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ssion expires Ok 20,
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Book 2244 Pacgeti- 126 Seq- 3

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BOOK 2 2 4 4 PA6E 7 2 9
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rr -Certification by Landfill Operator (if different from Owner):
I ce'rtifyhat the information provided by me in this notification is true, accurate, and complete to
the best of my knowledge. The facility siting and disposal operations of this Land Clearing & Inert
Debris ianafill will comply with the requirements of Sections .0563, .0564 and .0566 of 15A NCAC
13B, NoftbiCarolina Solid Waste Management Rules. The facility and operations of this landfill will
afso comply with all applicable Federal, State, and Local laws, rules, regulations, and ordinances. I
.have itiformed the land owner of my plans to dispose of solid waste on the land and the land owner
;r has ,specifically granted permission for the operation of the landfill. I understand that both the
f opgrat(oe and land owner are jointly and severally liable for improper operations and proper closure
of,theiian6fiil as provided for by North Carolina General Statute 130A-309.27. I further understand
thrat North Carolina General Statute 130A-22 provides for administrative penalties of up to fifteen
J/rthousja'nd dollars ($15,000.00) per day per each violation of the Solid Waste Management Rules. I
further understand that the Solid Waste Management Rules may be revised or amended in the
future and that thl6,,faciiity siting and operations of this landfill will be required to comply with all
such revisipiiia or aniendments.
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Plat Name (pperator).- Signature (Operator) Date
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North Carolina
County-,
!, a i' ptary Public for said County and State, do hereby Certify
That aim �� a , ,%;: pers ally appeared before me this day and acknowledged
ution of,the fol;egoing Instrument.
and''•officikP seal, this iVe f f , days ofOT
20
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��•. . `�.*„`^• y� f �. '• r Notary, PUbhC
•., i,efon expires ` c 3© 20 ��i I '
For additional land owners and lanAl operators, attach separAe noJ0z,4d certifications for each additional
land owner and landfill operator. I-f
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For Corporate land owners and/or operat6rg,;I�s,6' the Corporatte Certification:§, pages 5 and 6. Contact the
Division of Solid Waste Management for proper applicable, 'erl�ifit ati�rS. ' •1 _ {
INSTRUCTIONS '
Purpose- Notification of Land Clearing and Inert Debris LandFrfls under. two (2) acres In size is required u} der 15 NCAC 138 .0563(2)(a), Contact the Solid
Waste Section at the address below for further Informatr
Distribution: Mail completed recorded original notification to the folloWng ddoress; 1
Division of Solid waste Management r
Solid waste Section
PO Box 27887
Raleigh, North Carolina 24184ti-;F8
[phone]
Disposition: This form will be transferred to the State Records Center when referigce value ends. Records will be held''for agency in the State Records
Center five (5) additional years and then transferred to the custody of7he Archives.
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Book 2244 Pacgeti- 126 Seq- 4

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Certification by Landfill Operator (if different from Owner):
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I'.cer[fy that the information provided by me in this notification is true, accurate, and complete to
the best of my knowledge. The facility siting and disposal operations of this Land Clearing & Inert
Debris 1�ndfll will comply with the requirements of Sections .0563, .0564 and .0566 of 15A NCAC
•13B, North Carolina Solid Waste Management Rules. The facility and operations of this landfill will
also,ccomply with all applicable Federal, State, and Local laws, rules, regulations, and ordinances. I
have informed the land owner of my plans to dispose of solid waste on the land and the land owner
has specifically granted permission for the operation of the landfill. I understand that both the
operptor and land owner are jointly and severally liable for improper operations and proper closure
of the landfill as provided for by North Carolina General Statute 130A-309.27. I further understand
r thaf Nortti-Carolina General Statute 13OA-22 provides for administrative penalties of up to fifteen
thgi'jsand dollars ($15,000.00) per day per each violation of the Solid Waste Management Rules. I
further understand that the Solid Waste Management Rules may be revised or amended in the
future and that'the facility siting and operations of this landfill will be required to comply with all
/ such revAaions or"9mendments.
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'XPrint,Nami (Operat r} Signature (Operator) Date
Pt— ;1-7970
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North' Carolina a - S 3 Z — 75 Z—cl
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CouRty
1, I t N,:_INotary Public for said County and State, do hereby certify
appeared before me this day and acknowledged
f+8 tion of thi forgoing in!strutrtent. i •
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iilnd of tal seal, toil t ie ) ay of i 20 .
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. ` • �� N6tary Public
on expires — 2s� DO
For additional land owners and landfill operators;, attach "rate! mtorized certifications for each additional
land Owner and landfill operator. l ti_ f r ti
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For Corporate land owners and/or opi?rato,;s,rfise the Corporate Certificailions, pages 5 and 6. Contact the
Division of Solid Waste Management for proper applicable certfft'
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INSTRUCTIONS ,
Purpose: Notification of Land Gearing and Inert DaWs Landfill"nder two.(2) acres iq'size is required under 15 NCAC 13B .0563(2)(a} CooLbd the Solid
Waste Section at the address below for further irxozmetion. r
Distribution: Mail completed recorded original notification to the fo lo�eng address; 1�
Division of Solid Waste Management f'
Sdid Waste Section '
PO Box 27687
Raleigh. North Carolina 27611-7687
[phone]
Disposition. This form will be transferred to the State Records Center when rtiference valuiq ends. Records will be held for agency in the State Records
Center five (5) addition) years and then transferred to the custody of the Aw_hw vs,
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Book 2244 Pacgeti- 126 5eq- 5