NCC222672_FRO Submitted_20220725

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/orfax information unavailable, place N/A in the blank.)
Part A. nI
1. Project Name ( ) h i+c plos M HP Pk it
2. Location of land -disturbing activity: County CL e Lr.,J City or Township Grov1 r
Highway/Street LentibMtk Latitude 35•19$0 Longitude _V-4606
4.1
3. Approximate date land -disturbing activity will commence: Z, 6a6
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Kas;4A.A.Ct
5. Total acreage disturbed oruncovered (including off -site borrowand waste areas): `i• 55
6. Amount of fee enclosed: $ 4, 3a5. Od . 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? YesNo Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tyler �S
E-mail Address_ •do,S+on
Telephone Cell # 7oy -73y - 7806 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
J. H0,4 ton propa -tic 5 GLC
70 q - 73Y- V06
Name
Telephone Fax Number
10/5 Lac M046, 4
J015 Zeth Anf011114 91 _
Current Mailing Address
Current Street Address
llh11 h9/„
A'n15 A1A /0
a�oS6
City State Zip
City State
Zip
10. Deed Book No. /tit Page No.
U 17 Provide a copy of the most current deed.
Part B. �
1. Person(s) or firm(s) who are financially
responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties
on an attached sheet):
A 1qoa5fon AP[r7Fie5 Ue
J•trou5t°nf�!°�Gr'�IeSLw l7irta�iCo►n
Name
E-mail Address
1015 La �e /fiarr for�iu �d
1615 44t /'7%Qn�v wi
Current Mailing Address
Current Street Address
/e„ j s At% NL
Kn 45 4A /V(f
AM
City State Zip
City State
Zip
Telephone 7oN- 73Y- 7866
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
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 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
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
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.
T•,FQlls
Type or'print name
Sign6ture
M
I6bin
O,aner
Title or Authority
7Ai lao2a
Date
a Notary Public of the County of G mt -i
State of North Carolina, hereby certify that -T -0e c TraUs appeared
personally before me this day and being dul sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 011 day
����:R�OBUySOy
vs�
of J 20
Notary
My commission expires _ OLY c3-�