NCC222300_FRO Submitted_20220624

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.
Project N
2. Location of land -disturbing activity: County/�'?G ev s<JG2 I"�1 City or Townshipy�%U'}
HighwaylStreet G5� 1 �t/i�Y �t� '.Latitude 3j�;. �l �—
_ _Longitude
3. Approximate date land -disturbing activity will commence: )Lie
e
4. Purpose of development (residential, commercial, industrial, institutional, etc.): �s; d
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7-
6. Amount of fee enclosed: $ _. 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 i
No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name L) Jt5 L 0' E-mail Address --At t r � - r
i
Telephone
Cell # '�t"`_-fir _ t c 3 a Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Name j
Current Mailing Address
a•lo �r� tr(JG $�7U
City State Zip
10. Deed Book N
Part B.
5/ - 6'0L
Telephone Fax Number
Current Street Address
City
State
Zip
Page No. Provide a copy of the most current deed.
Company (les) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) !f the company or frrm is a sole
proprietorship the name of the owner or manager maybe listed as the finan�cia, lly,responsible party.
Name /� E-mail Address
220 g R efa t-1 cr MCurrent ailing Address Current Street Address
rlv_ /VC ;2g-�
Cif` State Zip
City
State
Zip

Teleph
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
Fax Number State Zip
(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 Marne. 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
E-mail Address
Current Street Address
State Zip City
Telephone
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
agree to provi
the authority to execute instruments for the Financially Responsible Person). 1 de
corrected information should there be any change in the information provided herein.
Type or print na Title or Authority
Sig _ urey Date 3
a Notary Public of the County of
appeared �-� G ���/c //-
State of North Carolina, hereby certify that t" � —S;I
personally before me this day and being duly
by him. sworn acknowledged that the above form was executed
Witness my hand and notarial seal, this day of
Ryan Chandler --- Notary
f IGWY PUBLIC
Mecklenburg County ommission
North Carolina My cexpires
My Commission Expires 08-19-2025