HomeMy WebLinkAboutNCC215280_FRO Submitted_20210927FINANCIAL 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.
1. Project
2. Location of land -disturbing activity: County City or Township�e���a
Highway/Street -5eo Latitude 5-S7 1�c3 i S Longitude
3. Approximate date land -disturbing activity will
commence: -5-- / q — off. I
4. Purpggseo development (residential, commercial, industrial, institutional,
etc.): r� 91 CC. '
5. Total acreage disturbed or uncovered (including off -site borrow and waste
areas): 0 , —1(0
6. Amount of fee enclosed: $ <�-�00 . The application fee of $65.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee
is $585).
7. Has an .�xosion and sediment control plan been filed? Yes No
Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
�QsSt�� e�'�
Name �'- s E-mail
Address
Telephone Cell Cell # Fax
9. Landowner(s) of Record (attach accompanied page to list additional owners):
4-u. s�-e s -'73U -'taa e-/
Name Telephone Fax Number
/- mar,d& Plt4kes 7o-,2--70 - �& 9 ,;?-
Current Mailing Address
iiys D' 1tt,n Ave
Current Street Address
AJC_ v2-71e) %
City State
Zip
:50- AN-C 6%5 fte,k 1��%
Zip City
State
10. Deed Book No. Page No. ON 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.
Name E-mail Address
Current Mailing Address
Current Street Address
City State Zip City
State Zip
Telephone
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
Current Mailing Address
City State
State Zip
Telephone
Number
E-mail Address
Current Street Address
Zip City
Fax
(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
Current Mailing Address
City
Zip
E-mail Address
Current Street Address
State Zip City
Telephone Fax
Number
State
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.
Type or print name
C
ignature
Title or Authority
5 —(' 2I
Date
I, C IVVtj a Notary Public of the County of _b�L
State of North Carolina, hereby certify that J_Cism CL,4 h _ appeared
personally before me this day and being duly sworn ackno ledged tha' he above form was
executed by him.
Witness my hand and notarial seal, this day of �20� `__
Seal
expires to
a.I A�,
Notary
Vanessa C. Gainey
Notary Public
Davidson County,
My Commission Expires 1)10