NCC220054_FRO Submitted_20220111

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. RED OAK BATTLEBORO RD. SUBDIVISION
1. Project Name
2. Location of land -disturbing activity: County NASH City or Township RED OAK
Highway/Street SR 1524 Latitude36.0373 Longitude-77.8615
3. Approximate date land -disturbing activity will commence:JANUARY 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.):RESIDENTIAL
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 15.4
6. Amount of fee enclosed: $ 1040 . 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 EnclosedX
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address
KEVIN VARNELL [e-mail]
Telephone[phone] Cell # 252.382.0012 Fax # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
REGES CLAUDETTE BECKY SMITH
Name Telephone Fax Number
2010 NORTHERN NASH ROAD RED OAK BATTLEBORO ROAD
Current Mailing Address Current Street Address
ROCKY MOUNT, NC 27804 RED OAK, NC 27868
City State Zip City State Zip
10. Deed Book No. 2700 Page No. 266 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.
FIVE L FARMS, LLC [e-mail]
Name E-mail Address
PO BOX 1812
Current Mailing Address Current Street Address
WILSON, NC 27896
City State Zip City State Zip
Telephone[phone] Fax Number252.459.8197

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
Telephone
E-mail Address
Current Street Address
State 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 State
Telephone
E-mail Address
Current Street Address
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.
LESLIE LILES
Type or print name I 40A
ignature
Awj�
Title or Authority
/0/,27/)-(
Date
I, �. L•t,�i�n 1%p���(,� a Notary Public of the County of �c
State of North Carolina, hereby certify that Sappeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,
J. KEVIN VARNELL
Notai giublic
North Carolina
Edgecombe County
this 277 day of , 20 2 (
"e�l J'e:� L60
Nota
My commission expires //,e 2 3