NCC221071_FRO Submitted_20220316

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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.
1. Project Name Mayberry Chrome Shop
2
3
4
Location of land -disturbing activity: County Surry City or Township Mt Airy
Highway/StreoA Oak Grove Church Rd Latitude 36.474487 Longitude -80.752015
Approximate date land -disturbing activity will commence:
Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900).
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 Mitchell Bottomley E-mail Address. [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MM Bottomley Properties LLC 336-372-5252
Name Telephone Fax Number
6460 Glade Valley Road 6460 Glade Valley Road
Current Mailing Address Current Street Address
Ennice NC 28623 Ennice NC 28623
City State Zip City State Zip
10. Deed Book No. 1793 Page No. 347 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.
MM Bottomley Properties LLC [e-mail]
Name E-mail Address
6460 Glade Valley Road 6460 Glade Valley Road
Current Mailing Address Current Street Address
Ennice NC 2$623 Ennice NC 28623
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
Telephone
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
Party is a Corporation, give name and
of Assumed Name. If the Financially Responsible
street address of the Registered Agent:
------------------------
Name of Registered Agent
E-mail Address
Current Mailing Address
Current Street Address
City State
Zip City
Telephone
State Zip
Fax Number
(c) In order to Facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary
BREC, PA
information regarding the plan and its preparation:
Engineering firm or other consultant
rnaxbrec,biz
Max Prestwood
E-mail Address
Individual contact person (t
336-844-4088 NA
ype ar pant) 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 Financiaily 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.
gat
Type
Signatur
Title or Authority
Dafe
a Notary Public of the County of ! le an
State of North Carolina, hereby certify that M y �F � p
before me this d being duly sworn acknowledged that the above form was execu#ed by himappeare.
personally
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