NCC223395_FRO Submitted_20220929

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 and within the
corporate limits or the extraterritorial jurisdiction of the City of Burlington before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Burlington's
Erosion Control Administrator. (Please type or print, if the question is not applicable or the e-mail and/or fax
information unavailable, place N/A in the space provided. Blank spaces and/or inaccurate information will be
considered incomplete and could result in a disapproved plan.)
Part A.
1 Project Na
Manle Leaf Storage
2. Location of land -disturbing activity: County AlamanCe City or Township Burlington
Highway/Street Maple Ave Latitude 36.057043 Longitude-79.435208
3. Approximate date land -disturbing activity will commence: Upon Permitting
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Storage / Office
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.1 Acres,
6.
Amount of fee enclosed: $ 345.00 . The application fee of $225 for the initial 2 acres
plus $60 per acre (rounded up
to the next acre) is assessed without a ceiling amount (Example: a 9-
acre application fee is $645).
7.
Has an erosion and sediment control plan been filed? Yes No x Enclosed x
8.
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Christopher Powell
E-mail Address [e-mail]
Telephone [phone]
Cell # n/a Fax # n/a
9.
Landowner(s) of Record (attach
accompanied page to list additional owners):
North Top Flex, LLC
336-350-9752 n/a
Name
Telephone Fax Number
1635 Nova Lane
1635 Nova Lane
Current Mailing Address
Current Street Address
Burlington, NC 27215
Burlington, NC 27215
City State
Zip City State Zip
10.
Deed Book No. 4263
Page No. 526 Provide a copy of the most current deed.
11.
Tax Map No. 6-6-29
Block Lot No.
12.
Parcel ID 130716
GPIN (State ID) 8873194865
Part B.
1.
Person(s) or firm(s) who is
financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
North Top Flex, LLC
[e-mail]
Name
E-mail Address
1635 Nova Lane
1635 Nova Lane
Current Mailing Address
Current Street Address
Burlington, NC 27215
Burlington, NC 27215
City State
Zip City State Zip
Telephone [phone]
Fax Number n/a

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:
n/a
Name
Current Mailing Address
City
Telepho
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:
n/a
Name of Registered Agent
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
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.
Q4 s CZ Le -y �Oc�! e Il Kgtc/h e '
Type or print name Title or Authority
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Signature Date
1 tf d�f� a Notary Public of the County of 4111ACl
State of North Carolina, hereby certify that i' liji ��!%iappeared
personally before me this day and being duly sworn acknKwtddged that the above form was
executed by him.
Witness my hand and notarial seal, this �'��'� day of j4d , 20
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JANETABARKER 4Not
bN�O,Y�Y PUBLIC
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My Commission Expires February 7, 2023