NCC220729_FRO Submitted_20220211

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. {P)ease 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: Gillis Hill Building Addition
2. Location of land -disturbing activity: County Cumberland City or Township Fayetteville
Highway/Street SR1102 / Gillis Hill Rd. Latitude 35,023196 Longitude -79.05266E
3. Approximate date land -disturbing activity will commence:
4. Purpose of development (residential, commercial, industrial, institutional, etc.); Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.25
6. Amount of fee enclosed: $200.00 The application fee of 100.00 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585.00).
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 Salah Hassan E-mail Address
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Sal's Investments, Inc. 910-684-0312
Name Telephone Fax Number
306 North Jackson Street Sarre
Current Mailing Address Current Street Address
Raeford, NC 28376
City State Zip City State Zfp
10. Deed Book No, 10907 Page No. 033E . Provide a copy of the most current deed.
Part B.
1. Company (ies) 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 parry.
Sal's Investments, Inc.
Name
306 North Jackson Street
Current Mailing Address
Raeford, NC 28376
City State
Telephone # [phone]
E-mail Address
Same
Current Street Address
City State Zip
Fax #

Z. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
NIA
Name
Current Mailing Address
City State Zip
Telephone #
E-mail Address
Current Street Address
City State Zip
Fax #
(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:
NIA
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone #
E-mail Address
Current Street Address
City State Zip
Fax #
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.
-S'L f4 L. IV, 1"4 S el .z
Type or print name
Signature
01--i "'ey­
Title or Authority
1 -"i - .1
Date
a Notary Public of the County of
State of North Carolina, hereby certify that �I .n 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 day of _ Zpz 1.
Ronda Kay Snyder
NOTARY PUBLIC Np
CuSkOand County
North Carotins r�
p„iy ornmMlon bras r - jMy commission expires