NCC216512_FRO Submitted_20211123

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 N/A in the blank.)
Part A. Holt Farm
1. Project Name
Holt
Location of land -disturbing activity: CountyAlamance City or Township Snow Camp
Highway/Street
I hwa /Street Latitude Longitude
4601 Mt. Hermon Rock Creek Rd 35.978764-79.422843
9 Y
3. Approximate date land -disturbing activity will commence: November 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3
6. Amount of fee enclosed: $ 1 95.00 . 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 erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Chad E. Abbott E-mail Address [e-mail]
Telephone [phone] Cell # 9 1 9-625-7368 Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
G'iwt�t22o,J GAPrr'�� i�yG' 919-880-6297 NA
Name Telephone Fax Number
2330 Operations Dr. 2330 Operations Dr.
Current Mailing Address Current Street Address
Durham, NC 27705 Durham, NC 27705
City State Zip City State Zip
10. Deed Book No. 41 79 Page No. 896 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.
'fIA41f2/tW c, 11F,01 [e-mail]
Name
2330 Operations Dr
Current Mailing Address
Durham, NC 27705
City State Zip
Telephone [phone]
E-mail Address
2330 Operations Dr
Current Street Address
Durham, NC 27705
City State Zip
Fax Number NA

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:
NA
NA
Name
E-mail Address
NA
NA
Current Mailing Address
Current Street Address
NA
NA
City State Zip
City State Zip
Telephone NA
Fax Number NA
(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:
NA
NA
Name of Registered Agent
E-mail Address
NA
NA
Current Mailing Address
Current Street Address
NA
NA
City State Zip
City State Zip
Telephone NA
Fax Number NA
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.
.S.- �2arG ivl
Type Or print name
S
Title or Authority
Date
I,/ Car®I a Notary rq_n o
Public of the County of � j �-
State of North Carolina, hereby certify that �� Cry rGj �n t-r'/,5670 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. -
Witness my hand and notarial seal, this day of �d e-r , 20 21
Notary
My commission expires N a V- 2 W. 202 3