NCC220392_FRO Submitted_20220120

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 NIA in the blank.)
Part A. Hot House Road Work
1. Project Name
2. Location of land -disturbing activity: County Cherokee City or Township Murphy
Highway/Street Charles Laney Rd Latitude35.044903 Longitude-84.246064
3. Approximate date land -disturbing activity will commence: l 24-22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): tower site
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):2.292
6. Amount of fee enclosed: $ . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yesx No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steve Forrester E-mail [e-mail]
Telephone[phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Charles & Faye Laney
Name Telephone Fax Number
1246 Charles Laney Rd
Current Mailing Address Current Street Address
Murphy, NC 28906
City State Zip city State Zip
10. Deed Book No.556 Page No.61 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.
Midland Communications, Inc [e-mail]
Name
Po Box 1178
Current Mailing Address
Calhoun, GA 30703
city
State Zip
E-mail Address
1363 Newtown Church Rd
Current Street Address
Calhoun, GA 30701
City State Zip
Telephone[phone] Fax Number706-624-1846

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 E-mail Address
Current Mailing Address Current Street Address
City 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:
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone.
E-mail Address
Current Street Address
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 attomey-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.
Christy Putnam CFO
Type or print name
NA &n�_
Signature
Title or Authority
1-18-22
Date
a Notary Public of the County of Gordon
State of-Pf� mina, hereby certify that Christy Putnam 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, this 18th day of January , 2C22
(•f,'�lM' �'nG' Notary
S r
2-2-22
tW- My commission expires
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