NCC217139_FRO Submitted_20220112

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 Environment and Natural Resources. (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.
1. Project Name Ha(-(Aen
2. Location of land -disturbing activity: Count City or Township
Highway/Street UJ f' e- LAf? C= Latitude � �� J\ Longitude p �fp
3. Approximate date land -disturbing activity will commence: t I o-O 9, 1
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Re.`jlC{��fl rl �. !
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): q . e) 11
6. Amount of fee enclosed: $ . 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 V No Enclosed
8. Person to contact should erosion and sediment control issues arise during landd-disturbing activity: t
Name VP--\) t �h��-��tC�.c� e, E-mail Addresst�
. L u t f) SY A6 r�-
Telephone 31 `�� Iq Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State
10, Deed Book No.
Part B.
Zip City
State
Zip
Page No. Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsibl parties on an attached sheet):
����,
Name l , , ,, / E`rri}ail'Address
11, 2') 5 9-
tam-e.
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone (10_ LVW_019 LO Fax Number N

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 Environment and Natural Resources. (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.
1. Project Name HaCoAen
2. Location of land -disturbing activity: County City or Township
Highway/Street LUf e— Lae? e- Latitude � �� `fin ©� Longitude y
3. Approximate date land -disturbing activity will commence: t f)-O
4. Purpose of development (residential, commercial, industrial, institutional, etc.): R���Idfein
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): q ,y tl
6. Amount of fee enclosed: $ . 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 I/ No Enclosed
8. Person jtoo contact should erosion and sediment control issues arise during land -,disturbing activityy:^ t
Name C P -y „11 �h��} Cic�C e_' E-mail Address Ye-U I n SyAo r �KtA � 13c' TM t! , txb Pk
Telephone (ItI t1) ,30,1 -611Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
/'
Name Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City
10. Deed Book No.
Part B.
State
Zip
Page No. Provide a copy of the most current deed.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsibl parties on an attached sheet):
Name r-rrtit"Address
Current Mailing Addresses \ Current Street Address
City State Zip City State Zip
Telephone q 10_ ��'3��D� 9 LP Fax Number 01 A"

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
E-mail Address
Current Street Address
State Zip City
Telephone Fax Number
State Zip
(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:
-J-S17 1't 1 nS - �o�..� • Cell
Name of Registered Agent E-ma ddress
wS 4�: U"S.'-
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone���3� "�gk (' 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.
�_rciSrArN 'S . �o���a�r �S j.�
Type or prin_ _ t Title or Authority
Sign
Date
,® - 2.0'
I, Zf%/ C 7k-)0u 7 , a Notary Public of the County of
State of North Carolina, hereby certify that 47//fpw appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness��VWdi �Vnotarial seal, this
�s0TAR^�, r
qNf i i 1 i t ��''����
1,9 day of 20
Notary
My commission expires�Ga Y /"�"s�