NCC217086_FRO Submitted_20220105

FINANCIAL RESPONSIBILITYIOWNERSHIP 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, it the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. PVG Trucking Warehouse, Inc.
1. Project Name
2
3
4
5
Location of land -disturbing activity: County'Stanly City or Township Locust
Highway/Street Locust Level Drive Latitude 35° 14' 43.47" Longitude 800 27' 2.52"
Approximate date land -disturbing activity will commence; January 4, 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.47
6, Amount of fee enclosed: $ 455 . 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 Daniel Gusev E-mail Address [e-mail]
Telephone [phone] Cell # [phone] Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
PVG Holding Inc. [phone] [phone]
Name Telephone Fax Number
405 West Main Street 405 West Main Street
Current Mailing Address
Locust, NC 28097
City State
10. Deed Book No. 1745
Zip
Current Street Address
Locust, NC 28097
City State Zip
Page No. 521
Provide a copy of the most current deed.
Part B.
1. Company(les) 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.
Daniel Gusev [e-mail]
Name
405 West Main Street
Current Mailing Address
Locust, NC 28097
City State Zip
Telephone [phone]
E-mail Address
405 West Main Street
Current Street Address
Locust, NC 28097
City State Zip
Fax Number [phone]

2. (a) It 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 State Zip
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 Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip 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
corrected information should there be any change in the information provided herein.
Daniel Gusev
Type or print name
CEO
Title or Authority
Signature Date
I, CaAdaCe //A�/ c1 a Notary Public of the County of
State of North Carolina, hereby certify that Pznte'l 64,5e✓ _ 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,
,11, 16111/j//
•��,OPC� H,g T� /��':
v� NolARY
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'ff"r, Y C UUNA
this �f day of NeVeyt,ber 20 -q
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Notary
My commission expires Wa_r0-- 13 2'DO