NCC230218_FRO Submitted_20230125

FINANCIAL RESPON8IB]LITYk}VVNERSH|PFORM
SEDIMENTATION POLLUTION CONTROL ACT
Nope.mmmay initiate any land disturbing activity on one or more acres as covered by Iho/ct before this
fo/mo»donazmptab|verosion and sedimentation control plan have bean completed and approved by the
Land 0oa|/wSection. NC. Department ofEnvironment and Natural Resources. (Please typo orprint arid, if
the (itiostion is not applicable or the e,mail and/or fax information unavailable. place NIA in the blank.)
Part A.
1- Project Numo.1o11Q Tedtnoloo-- 2. Location Lunahunuf|ond-WvWAbinOactivity: Cnunty_U8j0ACi(yo/TnwnsN^�d�»TmU-____'
HiVh*uySxae Latitude 35073456 Louguodn-OO838436
3 Approximate date |und-diniurbingactivity will nommnnra: Ooob*r2O22__________'-__'_____
4. Purpose of development (residential, commercial, industrial, institutional, etc.):corninercial
5� Total acreage disturbed or uncovered (including off -site borrow arid waste, areas),
& Amount offee enclosed: fee d$66-OOpar(rounded
upmthe next acre) /o-assessed without ecalling amount (Examp|e:m8'aomapplication fee is $585).
7. Has anerosion and sediment control plan been filed? Ya No_______Enu|uaad______-
& Person to contact should erosion and sediment control issues arise during land -disturbing activity:
NameE-mui|Addmn
Tel opt une-_7(���C�D08�Cn||A Fax4
9. Londwwnnr(o)ufRecord (attach accompanied page tolist additional mmnem):
704'201-8058
Name T�nph�eFax Number
------------
2S25Providence HU|sDrive
Matthews NC28|V5
uv State Zip City umue Zip
10, Deed Book No. 8066 Page No., 0394
Provide a copy Of tile most current deed,
Part B.
1. Porsm or NmM who are financially responsible for the kind-d kfbin autivity (provide m
comprehensive list o/all responsible portinyonanmOxohmdshuat)�
Ground Thunder Construction Inc buddy@Q(i253un/n
--"a||Add^o"s
PUBox ?D|OO8 511Johnson Rd
d"rra"|'W*ni-tN-Add,=s`------' -'-Cunnn\stroo\»(lx*o"' --
Charlotte NC 28200 Chudm0a NC 282U6
City- - �m��-�o city- ' s:x" - -Zip-

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_.-.-- _ --
-. ..
ame _
Current
Current Mailing Address
City State Zip
Telephone
E-marl Address
Current Street Address
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:
Robert E Weeks
Name of Registered Agent _
PO Box 791096
Current Mailing Address
Charlotte NC 28206
City
State Zip
Telephone [phone]
bob@gt1253 com
E-mail Address
511 Johnson Rd _
Current Street Address
Charlotte NC 28206
City State Zip
Fax Number
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.
.SAAE /iZm*c ✓id" do0
Type/pr print name /� Title or Authority
re
k 23-,20,.-Z
Date
I, �t /i7h�slt a Notary Public of the County of _Akw
State of North Carolina, hereby certify that 1*eF ffllm&E 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
WILLIAM POTEATE
NOTARY PUBLIC
Union County
Nor,th,(�arolina
My Commission Expires May 11, 2026
.73 day of /U,k(r _, 202 �
Notary
My commission expires______ S---11 zigi. ___