NCC220814_FRO Submitted (2)_20220217

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. Ph. 3 Fiberon 1 NL Western Storm System 2021
1. Project Name
IJ
3
4
Location of land -disturbing activity: County Stanly City or Township New London
Highway/Street 181 Random Dr. Latitude 35d 25' 8.0" N Longitude 80d 12' 37.4" W
Approximate date land -disturbing activity will commence: Aprl1 19, 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 0.5 acre
5. Amount of fee enclosed: $ 65.00 . 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 No Enclosed Yes
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity
NameJef Hardin
E-mail [e-mail]
Telephone 704`774-�7413
Cell # 704-774-7413 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nbvu London Investments
704-•463-7120
Name
Telephone Fax Number
181 Random Drive
Same
Current Mailing Address
Current Street Address
New London, NC 28127
Same
City State
Zip City State Zip
10. Deed Book No. 1067 Page No. 0332 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.
New London Investments
[e-mail]
Name
E-mail Address
181 Random Drive
Same
Current Mailing Address
Current Street Address
New London, NC 28127
Same
City State
Zip City State Zip
Telephone [phone]
Fax Number

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 State Zip
Telephone
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
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City state Zip
Telephone
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.
Susan Saunders New London Investments Controller
T pe or print nkne Title r Authority
tR 2oz1
Signature Date
C) a Notary Public of the County of 5
State of North Carolina, hereby certify that of 2 _ �� �� r��_ 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 1 9 day of 14 er + 209_
k� J A*
Notary
Seal
My commission expires 6a /a O ps-