NCC230059_FRO Submitted_20230112

RECEIVFP.,r
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM �
SEDIMENTATION POLLUTION CONTROL ACT F 9 Q0 1 20
No person may initiate any land -disturbing activity on one or more acres as covered 6{t,�!rlA- Fi=IC
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 NIA in the blank.)
Part A.
1. Project Name �./'t'i G F/,_J
2. Location of land -disturbing activity: County (,a w &ZJ0,4L-341-ongitude
or Township
HighwaylStreet 'Td` [ Latitude 27 / t l
3. Approximate date land -disturbing activity will commence: l '�
4. Purpose of development {residential, commercial, industrial, institutional, etc.):_ A�51ji'4•74-J«7
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ ��� . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount Example: 8.10 ac = $900.00).
7 ? Has an erosion and sediment control plan been filed. Yes No Enclosed
8. Person to contacts uld erosion and sediment control issues arise during land -disturbing activity:
Name E-mail Address' �� � /7��1'1��l` 41)�
Telephone��1 �,��J Cell # ��y ��%'2Z Fax #
9. Lan owner{s) Record (attach a companied page to list additional owners):
Name Telephone Fax Number
OO
7Curr nt Mailin Address Current Street Address '
121"�W-JlfAle 19�11
City 1 State Zip City State Zip
10. Deed Book No. Page No. c1 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) if the company or firm is a sole proprietorship,
the name of the owner or manager ay be listed as the financially responsible party.
DYlT l t %d�il�1513T � tzs ® a�'Ivv
Name -mat Address
1 S i ' 0 s� �a
Current Mailing AddrLdss Current Street Address
i&4 � _X/f /L 76elA a ��
City State Zip City State Zip
Telephone 7 ly 1 ?7 '/2S(O 2_ Fax Number 'r'�

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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 State
Telephone.
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(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
Telephone
E-mail Address
Current Street Address
State Zip 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 informat
ion should there be any change in the information provided herein.
IV.
Type nn name Title or Authority
Tana re Date
I, K AerW VbVAq)A , a Notary Public of the County of U rt I
State of North Carolina, hereby certify that Uftr� W _ Ub' A5pV\ appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 6"1day of (r� , 20��
,q,if 11 Ni, ,,l•,•
o$
Notary
Seat n :
. �A;,; My commission expires