NCC217188_FRO Submitted_20220105

FINANCIAL RESPONSIBIL,ITYIOWNERSHIP 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 acceptabfe 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.
2_ Location of land -disturbing activity: CountyjE 40-n�,/n bV,,XQ City or Township Wi iMiY1� D40
Highway/Street] Latitude 21 1 , 11+4 d Longitude — e7 g- p�
3. Approximate date land -disturbing activity will commence: '3 L7/7_
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Resi ,�cd
5. Total acreage disturbed or uncovered (including off site borrow and waste areas): 0, 1 2
6. Amount of fee enclosed: $ NA . The application fee of $66.00 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 arise during land -disturbing activity:
Name 9"l4ayl E-mail Address t-UOlal�&90UJe& iI&YS.ClJM
Telephone_ 61 t D - EX I - q' 3 Wn Cell # � A � -- i` Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Seveyd Wf �uild�r5, Inc.- q1b- 324- 444uI N/A
Name i Telephone Fax Number
Pb Pox 1bq 0 t4M IAichiiA 1"7 .6UiV_ L
Current Mailing Address Current Street Address
IVwrnp5 N,C, p�e�r_ NG 2!44--
city State Zip City State Zip
1 0_ Deed Book No.� *g- I I Page No. Z 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.
$v1 Uex�. Inc. �� 9Q we�kl0� l� .card
Name E-mail Address
20 & x 169 0
Current Mailing Address
�Arjm NC, 2 s4-'-�
City State Zip
1q
Current Street AdAhress
tom. 2'� +�'5
city A State Zip

Telephone Fax Number N LA_
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:
V
Name E-mail Address
Current Malting 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 Name. If the Financially Responsible Party
is a Coirporaton, give name and street address of the Registered Agent:
N/rA
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)_ l agree to provide
corrected information should there be any change in the information provided herein.
Type or t name
Signatur
Title or Authority
12.13I I2�
Date
1, 080 lSsa, ( kk l�j I , a Notary Public of the County of ylnkn bl"
State of North Carolina, hereby certify that _0 it 1 Gd, appeared
personally before me this day and being duly sworn aG owledged that the above form was executed
by him.
Witness my hand�apd,optariial seal, this 5411*�r-day of . _D rMi ber' 20 Z1
4Notary Publicfiy
Johnston Notary
5�ai County
z My Comm. Exp. ZZ My commission expires Z
y 02-01-2026 Q
0 a