NCC215834_FRO Submitted_20211020

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. 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 NIA in the blank.)
Part A.
1. Project Name 0-1 O S G'o✓J S./rU CA'Opl
2. Location of land -disturbing activity: County CO IdWe ! City or Township
Highway/Street q~i�[
1' IGt+`kir1raW,�__ ?.'4 = &5, 185'10 Longitude `` 1, 33 1 as
atitu
3. Approximate date land -disturbing activity will commence: (0 1 i o 1 4. Purpose of development (residential, commercial, industrial, institutional, etc.): i i� -� e, Iidjo b'ar
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0,4 (V
6. Amount of fee enclosed: $ 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 erosion and sediment control plan been filed? Yes No Enclosed
8, Person to contact should erosion and sediment control issues ariseduringuring land -disturbing activity:
Name b v/1 c () _ t O 5 _ E-mail Address d_ e 0 S C�c yak 0 0 r t M
Telephone Cell # ��d o, 3�� -77Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
7� 0a Ie6oca '3eLo5_ ('W) 3Oq_- 5dsy
Name Telephone Fax Number
Current Mailing Address Current Street Address
wcmory 9e609
City State Zip City State Zip
10. Deed Book No. Jq'�:7 Page No. 107-1O 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.
a hp o c-N 5 C( -16elns � V0l�0o . (104"
Name E-mail Address
16 16- MOQ nu>M ( _
Current Mailih§ Address
�C !)l '2.
Current Street Address
#Ck orLr N cr M6
City J State Zip City State Zip

Telephone � eag ) z Da-5 05 c,
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
1616-
Current Mailiny Address
City State Zip
'
Telephone X: Zf _1 7`�r"
d.a 6c10S e1o400.r . t
E-mail Address
.go /rw-
Current Street Address
City
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, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone.
State
Zip
E-mail Address
Current Street Address
City State Zip
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). 1 agree to provide
corrected information should there be any change in the information provided herein.
Aga � eLcn D w /.e.�
kTyp or print name Title or Authority
/ 0 I,L2_ /
ig ture Date
I, � (A) —'_s)kVk,30n , a Notary Public of the County of
State of North Carolina, hereby certify that GL Q appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by him. n
Witness my hand and notarial seal, this 124 day of
KATHY W JOHNSON
Notary Publlc - North Car]20024
Burke County
My Commission Expires Aug 0 ,
My corn
20 2 1
on expires 2 ZV