NCC223521_FRO Submitted_20221013

H ig hwayi treet D ewro D r-1v
C i ter
FINANCIAL RE PONSIBILITYlOW lER HIE FORM
EDMENTATION POLLUTION CONTROL ACT
No person may initiate a n } 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 comp I-eted and approved by
the Lard Quality Section N.C. Department of Env i rori menta I Quality. Submit !he completed form to the
a pp ro priate Reg Tonal Office. (Please type o r pri nt a nd s if t h e question i s not ap p I ica bie or the a -ma 11 a n di
or fax information unavailable, place N/A in the blank.)
Part A. Do rGe Site Development
1, Project Narne
, Location of land -disturbing ar-tivity
di
Counter Barre - City or Township Silver Creel
Latit u de _-56 Longitude - 1-4 - 1
Approximate date land -disturbing activity will rr�r once,r)rt �? i
4. Purpose of development (residential, cornmercial, industrial, institutional, etc.) : Residential
5- ToteI acreage d istu rbed or uncovered (including off -site burr -and waste areas): 1.4 acres
6 - Amount of f-ee enclosed- 5 200.00 -The applicatio n fee of $100. 0 D per a c re
(rc u n ded u p to th e n ext acre) is assessed with o ut a ceiling amou rat (Exam pie' $,10 ac = $9 00-00 }_
7- Has an erosion and sediment control plan been filed? Yes N o F�ndused
8- Person to contact should erosion and sediment control issues arise during land-disturUng activity.
Name bandy Buchanan E-mail Ad -dress [e-mail]
Telephone
Cell # 71- 4 -94 38
1= ax r
9. La n downer(s) of Reca rd (attach ecco m pa n Ted age to I i �,r a dd itici al owners) -
andy & Robin Buchanan571-643-9438
Name
1001 Marina V1I[age Dr. Unilt 206
Current Mailing Address
Mount Holly NC 28120
City State Zip
1 0- Deed Book No. 7
Page No.
Telephone Fax Number
I OG 1 Marina Village Dr. Unit 206
Current Strut Add r ess
Mount Holly 120
City
323
State
Zip
Provide a oopy of the most current deed.
Part B.
1 Company(pes) or firm(s) who are financially responsible for the land -disturbing activity (Provide e
comprehensive Iist of all responsible panties on an attached sheet.) ff the pang or fora, is a sofa propfietorsh p,
the name of the of -mar or many may be listaef as the i+rrancrally mgponsib;�-, pa*.
Fundy Buchanan [e-mail]
Name Email Ad -dress
1001 Mar1na Tillage Dr. Unit 206
Current Tiling Address
Mount Holly NC 28120
state - - Zip
Telephone 71 -4-4
38
1001 Marina Village Dr. Knit 206
Current Street Address - ----
Mount Holly NC 28120
'E ity State Zip
Fax N iAm bar

. (a) If the Financially Responsible Party is not a resident of North Carolina, give r ame and street address
of the designated North Carolina Agent:
P
Name
E-mail Address
u rrent Ma i 11 ng Add ress Current Strut Add rem - — - --
city State Zip City state zip
Tel ephone Fax Number.
(b' If the F i na nr rally Responsible Party is -a Partnership or ether person engaging in business under art
assumed name, attach a copy -of the Certificate of Assumed Name. If :he F i na ncia Ily Responsible
Fla r + -is a G orpor ation, g ive n ame a n d street ad d ress of t h e Registered Agee t:
Narne -of Reg iste red Agent
u rTent Mailing Address
ess -
State zi:
Telephone
E-mail ,address
u r ent Street Address
City state Zip
Fax Number
The above information is true and correct to the best of my knowledge and belief and -Vv :� $ provided
by me under oath (This form must he 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 i ristru m e nts for the Financially Respc n si b Ce Person). I agree to provide
corrected i nformafi o n -should there be any change in the information provided herein.
Randy Buchanan
Ty: or print name
Title or Authorky
Signature Date
I, LA r) , � l e r Public of the curt} of &I —
Mate of North CaFolina, her-eby Certify that
personally before me this day and being duly
executed by him.
.. cl r�-A appeared
acknowledged that the above form was
Witness my hand and nota ri aI lea I, this day of�16 rNU r-, 20 .
r Kayla Daniels
.I ,SPY PUBLIC
Gastw Countyr N
- - - ---- J
My Gommission expires v