NCC215928_FRO Submitted_20211026

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 LIfflOVIP_VWn hOm)�
2. Location of land -disturbing activity: County RrsCity or Township Kernercyi I Ie
Highway/Street 1 os ri rLatitude 3(0. 0dj8 Longitudes ? D47� i
3. Approximate date land -disturbing activity will commence: Noye ix —AA
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ PQL�A . 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 V1 No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name ZG&i Cr'_ E-mail Address
Telephone ale Z6, w I Cell # TqR _A'---' - Lr LO I Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
IR 4 rRn , 11 r1
Name Telephone
�� P.kaC Gen-k1L1�' VV� , 11211 S�k
Current Mailing, Address Current Street Address
��o -\! �A1� IQL
City State Zip City State
10. Doed Book No. Page No.
Part B.
Fax Number
,Zip
Provide a copy of the most current deed.
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.
vlc >M2A )I Or! &oyf-on . Ckn
Name E -mail Addre s
Current Mailing Address Current Street Address
NLo 11 �15L�
City State zip City State Zip

Telephone 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 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 narle, 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 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 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.
dm�lca mpLAL N1� &1 �IQn� In1�7S 7v�
Type or print name Title or Authority
A 'lu "V- 0 D1 1
Sigr(alure ra Date
r `, 2. 0e_
a Notary Public of the County of �C
State of North Carolina, hereby certify that I'Cj4 M&44= appeared
personally before me this day and being duly sworn acknowled ed that the above form was executed
by him.
Witness my hand and notarial seal, this 4day of Q� , 20 09 I
GINAK, MOTSINGRR
FORSYTH COUNTY, NG My CortNotary
Ynws Lrrea
Seal
My commission expires