NCC222826_FRO Submitted_20220808

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name_ .' J gdel ; c 1 # i 1 S dA 4
2. Location of land-disturbingactivity: Count A :. + ' - ,
�q % /tY Y� r , . , City or Township lV !rA'v
Highway/Street lY� 1�2 S7- '/
Latitude(decimaidegrees V.d7�' Long itude(decimaldegrees)
' a
3. Approximate date land -disturbing activity will commence:_ A. / S Jim
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas);
6. Amount of fee enclosedkL_. The Express Permitting application fee is a dual charge.
The normal fee of $100.00 FAr acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition, the Express Permitting supplement is $250 peracre up to eight acres, afterwhich the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 8.10-acre application fee is $2,900), Checks
should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes llEnclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Q'*�;`Sa� E-mail Address
Phone: Office # _ �1(b c��� �03y Mobile # ( 4
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Phone: Office # Mobile #
3 ��Ad �► 3- 1Y1;1 �
Current Mails Current Street Addless
City State Zip City J State Zip
10. Deed Book No. CD y S S- Page No. Provide a copy of the most current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
'dal a41 Ih ,�J S� LL
Company Name
332. ,I`niii+c�,r.
Current Mailing A dress
City 3 State Zip
-,�
Ir�,b �-o� ir:b Liao e
E-mail Address
S0.ky
Current Street Address
City
State
Phone: Office # Cq(a� �S I- S63d Mobile # ( q 1 al �� 7 - 4-(Q 1
Zip
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
(a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
2d�24 A6%s ri\bI1(C k r; •�-
Name of Registered Agent E-mail Address
33 3- (6E 12d
Current Mailing Ad ress
City State Zip
s
Current Street Address
City
State Zip
Phone: Office # C0 b aSi Mobile # f9/o % 777
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the
(Certificate of Assumed Name.
NA
Company DBA Name
(d) If 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 information regarding the plan and its preparation:
�� iheo�nitant
.
Engineering firm or
I ►�, I�SCa�s
Individual contact person (type or print)
Qom
E-m�Addres!����'
MlOi �141- b70`7 lb,5a0 -I`i41
Phone: Office # Mobile #
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(s)
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 Party). I agree to provide
co„nrrected information should there be any change in the information provided herein.
tr l[ilI L -Qunn
Type or print name
Sign re
s
A
Date
a Notary Public of the County ofu-
State of North Carolina, hereby certify that __ 2,-
appeared before me this day and being duly sworn acknowledged that the above form was executed by h m/heir.
Witness my hand and notarial seal, this 3 day of _ k 2p 22
Not
zQTAq�
O
sal U My commission expires —A