NCC216039_FRO Submitted_20211103

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 L_�N Bo< � eSS QY--
2. Location of land -disturbing activity: County • 1Ci� Iwl City or Township Co�1�tl
Highway/Street 10%1 SC411(!J?cj Latitude Longitude-`?;7,fb'5_7q
I Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.): (0 NYIn(1 C,9C`I0.9
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2_>(.P
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 fled? Yes ✓ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Rn 1 19 WAV- E-mail Address CwNl M Ll�o Ccvl5 LCGYV-J
Telephone Cell # 27i Fax
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name
Current Mailing Address
City State
10. Deed Book No
Part B.
Telephone
Current Street Address
Zip City State
Page No.
Fax Number
Zip
Provide a copy of the most current deed.
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.
Cvmm m film CQ oat w. �c
Name
E-mail Address
P3 130 We - 52-0 ' am U� e�
Current Mailing Address Current Street Address
City State Zip City State Zip

Telephone CI VF? - q WU Fax Number(__7 0`i':� j -M
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
Telephone
E-mail Address
Current Street Address
Zip 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 State Zip
Teleph
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). I agree to provide
cted information should there be any change in the information provided herein.
L..,' : L IE n Q e,.%A�c
yp tint nam Title or Authority
L Za
Signature Date
1, �V 11 4 A c SLU , a Notary Public of the County of U
State of North Carolina, hereby certify that_ TV) 111 Q 2CkK:V'C12 appeared
personally before me this day and being duly sworn ackn w edged that the above form was executed
by him.
Witness my hand and notarial seal, this 2cO day of
KIMBERL.Y A MOSCUZZA r
NOTARY PUBLIC *oa y
Unhm,,Aounty
North ar sJu M commission expires rr��
My Commission Expires June 10, 2023 Y p reS �lirii [ V ZOZ,3