N0691 SPORTSMAN'S PARADISE

0769
0442
CF10
R8769 P0442
FILED
YADKIN COUNTY, NC
KAREN H. WAGONER
REGISTER OF DEEDS
FILED Feb 09, 2006
AT 02:20:01 pm
BOOK 00769
START PAGE 0442
END PAGE 0443
INSTRUMENT # 00820
.A-7—iA.
NCDENR
North Carolina Department of Environment and Natural Resources
Dexter R. Matthews, Director Division of Waste Management Michael F. Easley, Governor
William G. t2^ s _lt., Secretary
LAND CLEARING AND INERT DEBRIS LANDFILL NOTIFICATION
Pursuant to 15A NCAC 13B .0563(2)(a), the land owner(s) and operator(s) of any Land Clearing and Inert Debris Landfill
under two (2) acres in size shall submit this notification form to the Division prior to constructing or operating the landfill.
This form must be filed for recordation in the Register of Deeds' Office. The Register of Deeds shall index the notification
under the name of the owner(s) of the land in the county or counties in which the land 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 a landfill unless complete, accurate, recorded, and submitted to
the Division as required by 15A NCAC 13B .0563(2)ib).
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Facility Name:
Facility location (street add
City:-Ll.r✓11�1.(.�C
Direction q o Site:
,:G-:I
Name
S
County: /U L, Zio:
4 --kl—
and on which this landfill is located is dekribed in the deed recorded in:
d-k—,
f
Maiing address of land owner: v It �5C� 0 A_ o -,Tj1ti -
C4: LQfJ` L. h �jc�Q w�-. State: N Zip: i 1 C L
Telephone number of land owner: ( --'� E 1,, ) e 2A - u 14 ,�L-
if the land is owned by more than one person, attach additional sheets with the name, address, and phone
number of all additional land owners. �} l
8. Name of operator:_ �:A �. l.._c-� GLUCT- ,-
9. Trade or business name of operator: f o 5l"t`cz-KJ
10. Mailing address of operator:_ I �� i. `
City: L 1 . �1�) i1 Q_ State: `11 �1 zip:
11. Telephon number of operator: (3 L, ) q b I
If the landfill is operated by more than one person, attach additional sheets with the name, address, and phone
number of all additional operators.
12. Projected use of land after completion of landfill operations:
1646 Mail Service Center, Raleigh, North Carolina 27699-1646
Phone: [phone] FAX: [phone] Internet http:l/wastenotnc.org
An Equal Opportunity 1 Affirmative Action Employer - Printed on Dual Purpose Recycled Paper

0769
0443
R1769 P0443
Certification by Corporate Land Owner:
I certify 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 landfill 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 comply with all applicable Federal, State, and Local laws, rules, regulations,
and ordinances. Where the operator is different from the corporate land owner, the corporate land owner, has knowledge
of the operator's plans to dispose of solid waste on the land and is specifically granted permission for the operation of the
landfill. It is understood that both the corporate land owner and operator 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. It is further
understand that North Carolina General Statute 130A-22 provides for administrative penalties of up to five thousand
dollars ($5,000.00) per day per each violation of the Solid Waste Management Rules. It is further understood 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 cfo�mply with all such revisions or amendments.
Corporation Name (Print) Date
(Corporate Seal)
TV
President or Vice -President Name (Print)
President or Vice -President Signature
Attest:
Corporate Secretary Name (Print)
Corporate Sidcretary Signature
North Carolina
Fo?--.— County
I
44 t'4 � � $,S/ , a Notary Public for said County and State, do hereby certify
that �' c t� r- F��'�'`-rhame of secretary) personally appeared before me this day and acknowledged
that he (or she) is secretary of _/X0 6,2N('i1'e (name of corporation), a corporation, and that
nby authority duly given and as the act of the corporation, the forgoing instrument was signed in its name by its
u.S- LL1`fm� 9 /17 i Zw & (president or vice-president), sealed with its corporate seal, and attested by himself (or herself)
as its secretary.
Witness my hand and official seal, this the 5'VA' day of C d 20 0 k,
(Official Seal)
Notary Public
My commission expires �4 6 G► 20 /0
PAULA R. GOSS
Notary Public - North Carolina
County of Forsyth