NCC215851_FRO Submitted_20211021

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.)
Dart A.
Project Name
2. Location of land -disturbing activity: County NeuJkkt 6\W-r City or Township W i lmiy7Q-{- Y1
Highway/Street }Nhn(hVfLatitude �4 , k A-510 jLongitude
3. Approximate date land -disturbing activity will commence: 101111 Z6 ZI
4_ Purpose of development (residential, commercial, industrial, institutional, etc.): lze5iAenA a_�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.09
6. Amount of fee enclosed: $ Nl p� . 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 fled? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 9,\-4c.A _Q'ktt..E E-mail Address rUO-Y) irloweaux 8ey-S-66M
Q � J
Telephone p
p 91 541- S"�(qZ_ Cell u A Fax# NIA
9_ Landowner(s) of Record (attach accompanied page to list additional owners):
s a 10 - 314- 444''7 N11A
Name J Telephone Fax Number
?b BNx ibi 0 I4�99 hclnlry[xu ,17....;.SUik�_ C
Current Mailing Address Current Street AdAress
City State Zip `` cityts
itState Zi
10. Deed Book No. � 4r1q Page No. ! Z 12— Provide a copy of the most current deed.
Part B.
Company (les) or firm(s) who are financially responsible for the land -disturbing activity tProvide 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
20 FLx W90 140 HAKWrt 119 ��Z01 C,
Current Mailing Address Current Street A ress
� Nc L _ -n 44711
City State Zip City State Zip

Telephone —Fax Number A-
2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street, address of
the deshhignated forth Carolina Agent:
1
Nam a ' E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(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 Dame. If the Financially Responsible Patty
is a Corporation, give name and street address of the Registered Agent:
N /A _
Name fo Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 Parson 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 t name Title or Authority
� I 110Ll
Signatur Date
i, ;'GGO_ ck,w , a Notary Public of the County of
State of North Carolina., hereby certify that Crri C4 SNIA�) appeared
personally before me this day and being duly sworn ac1dowledged that the above form was executed
by him.
Witness my hand and notarial seal, this lgday ofC� p , 20�
SSAtt JEkll''
Notary Pubic ?t
Johnston Notary
Seal County =
My Comm. Exp. — My commission expires
2 02-01-2025 V.
SO N
RW