NCC221295_FRO Submitted_20220405

p1t, Coll
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 N/A in the blank.)
Part A. Smith Industrial Subdivision
1. Project Name
2. Location of land -disturbing activity: County CabarrUS City or Township Midland
Highway/Street 12400 Old Camden Rd. Latitude 350 14' 40.2" N Longitude 800 34' 19.56" W
3. Approximate date land -disturbing activity will commence: March 01, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.14
6. Amount of fee enclosed: $ 300 ($100x3acres) 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? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name William Smith E-mail Address [e-mail]
Telephone [phone] cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
William Smith [phone]
Name Telephone Fax Number
P.O. Box 319 12440 Grey Commercial Dr.
Current Mailing Address Current Street Address
Midland NC 28107 Midland NC 28107
City State Zip City State Zip
10. Deed Book No. 12352 Page No. 0182 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.
William Smith [e-mail]
Name E-mail Address
P.O. Box 319 P.O. Box 319
Current Mailing Address Current Street Address
Midland NC 28107 Midland NC 28107
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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City 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 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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
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.
co, o. 5rn tAl
Type or print name
1XVP1711�
Signature
r?- i bn�
Title or Authority
i II 2-1
Date
a Notary Public of the County of al! ;crk%
State of North Carolina, hereby certify that iv ZQ f a ; 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 �CB ��e�' 20
aSheila H Smith
NOTARY PUBLIC
eal union County, NO
My Commission Expitet Septomger 23, 2025
otary
My commission expires