NCC220132_FRO Submitted_20220107

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. Kerr Lake Stow N Go
1. Project Name
2. Location of land -disturbing activity: County Vance City or Township Henderson
Highway/Street 74 Crawley Road Latitude 36.363778 Longitude—78.374910
3. Approximate date land -disturbing activity will commence: J u ne 1, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.00
6. Amount of fee enclosed: $ 390.00 . 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 # 919-625-7368 Fax # NA
E
10
Landowner(s) of Record (attach accompanied page to list additional owners):
US3 Investment, LLC 919-710-1357
Name
74 Crawley Rd
Current Mailing Address
Henderson, NC
Telephone
74 Crawley Rd
Current Street Address
27537 Henderson,
City State Zip City
Deed Book No. 1317 Page No. 1075
NC
State
Fax Number
27537
Zip
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.
Reynold and Amy Hagg [e-mail]
Name E-mail Address
74 Crawley Road 74 Crawley Road
Current Mailing Address Current Street Address
Henderson, NC 27537 Henderson, NC 27537
City State
Telephone [phone]
Zip
City
Fax Number NA
State
Zip

(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
Name
NA
Current Mailing Address
NA
City
Telephone NA
NA
E-mail Address
NA
Current Street Address
NA
State Zip City State Zip
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
NA
Current Mailing Address
NA
City State
Telephone NA
E-mail Address
_ NA
Current Street Address
_ NA
Zip City State Zip
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.
Amy Hagg ��� 1���` Co -Owner
Type or print name '— Title or Authority
04/29/2021
S gnature Date
I, Al a Notary Public of the County of V(Affl,
State of North Carolina, hereby certify that _TZ appeared
personally before me this day and being duly sworn ackn edged that the above form was
executed by him. n n'
Witness my hand and notarial seal, this V t day of 20 (mil
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Seal _
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Notary
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