NCC221182_FRO Submitted_20220328

FINANCIAL RESPONSIBILITWOWNERSHIP FORM'
SEDIMEWATOmPOL UTION CONTROL ACT
No person m.6y initiate any land -disturbing activity on one -ar.moi-e acres as;c6Vered-by the Act:before.this: .
form, and -.en acceptable .erosion and sedimentation cantiol plan have baen completed, and approved- y .
the'Land Quality Section; :N.C.._©epartmerit of Environmental duality. Submit the ;completed farm to the. .
appropriate Regional Office.:(Please-type -or .-print a6d, If ,the question' is not applicable or thee -flail aiidl
or fax Information unavailable, place NIA Ln the blank:),
Part A.
1. Project. Name
2. • .Location of land-dlsturbing
:County.: �. t City or:T
Lor
3, Approximate -date 16nS. rst Bing activity will commence,/ D
4. Purpose of development (residential, commercial, industrial, institution. al, etc.);
5. .Total. acreage disturb d or uncovered'(lncludingOff-site-borrow and viiaste.areas): ��.
6. Amount of fee enclosed:$ The applicatlon fep of $65.QU per` acre,(rounded
up to the next acre) is assesse . without:a ceiling.arnount {Exam a.9-acre a�plieation feels $585)
7. Has an erasion and sediment,conteol plan been filed? Yes No Enclosed
8,- Person to contact should erosion phd'sediriient control issues arise"dudn' :Ib d4sturbing activity`.
Name E mall Address
Telephone. .Coll W. _ax #
9.° 'Landowner(s) cif R cord (attach accompanied page to!list additional arivpers.):
P-w
Name . Telephone. Fix' nber
Current Mailing Address �j . Current'Street Address
City. 3f4
te Zip City State:. zip,
10. Deed Book No. � Page No. Qrny)de � c©py a# the rriost cgrrent deed �.
Part.B
I.'- Compa-ny(les) .or: firms) who .are -financialiy`-responsible for the :-land=disturbing ;activity (Provide a
comprehensive list of ail responsible. parties on an attached, sheet,)1ghe,compeny or firirr is a sole proprietorship,
the name.of fhe owner or manager aj! boilsted as. fhe frn$ncfally responsible party.
E-Mall Address
Current Mailing Ai ddress ..current Street Address
City . State .- .zjp. City :`; State: , . Zip
Telephone Fax Number.. �i1

2. (a) If the Financially Responsible Party.is not a resident of North Carolina, give name and street address
of the designate.4 North Carolina Agent:
4
Name E-mail Address
Current Mailing Address Current Street Address .
City -State Zip. Clty 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 Assui:ned . Namo. If: the 'Ftnancially Responsible .
Party -is
�a jCo poratlon, give name and street address of the, Registered Agent:
Name of q6g1st6red Agent E-mail Address
Current Mailing Address Current Street Address
City. State zip. City .State
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 he signed'by the Financially -Responsible Person If an .individual -
or his attorney Iri-fact, or'if not an.individual, by an officer, director, partner,, or registered agent with
the authority to execut& instruments for the. Financially Responsible Person)... I agree to provide
corrected information should there be any change J6 t e information provided herein,
c &h
Type' rint na Title or uthorl y
nature' Date . :.
�A' 11� A 777
11 At. —� ZMA11- ,-.-, a Notary Publicf of the County. of
State of North Carolina, her®by certify that I appeared
6
personally before me this day and, being -d.uly sworn acknoWledged that the above form was
executed_ by him.
Witness my hand and notarial seal; this (-J day of , - a
Elizabeth.A Babb
IVOT;41fUBI:1G
New Hanover County, NG
My Commission Expires September. 24, 2023