NCC230328_FRO Submitted_20230208

Check if this project is ARPA-funded f _I
FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act, including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 NIA in the blank.)
Part A.
1. Project Name_ 3EL,,e_r C)CAJ�-_. �
'if this project involves Amencan Rescue Plan Act (ARPA) funds, list the Project Name below
under which you applied for funding through the Division of Water Infrastructure (DWI).
2. Location of land -disturbing activity: County UUc-kC City or Township Y`t
Highway/Street IQe_ e�_` _ LatitudeidLunimdog�aLong itude(oecftnvdegrmsy --7V. 93 yo
3. Approximate date land -disturbing activity will commence: G � ` S— 20a 3
A. Purpose of development (residential, commercial, industrial, institutional, etc.): P'ri9+�� ►+a�
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
I t I
6. Amount of fee enclosed: $ acyo . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8-1 0-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes Q Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name , ]yC-t E-mail Address ✓S Coh '4 % on • C oM
Phone- Office #t "'? L 9 - 9 aZ - a213 _� Mobile # 9 I9 - 4 3 -7
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ct R-y as - 67)9 Q14 9
Name Phone: Office # Mobile #
Current Mailing Address Current Street Address
]� a7502_ A2eV-
�l State Zip City State Zip
10. Deed Book No. D IS i -7 t Page No. ©i AV �_ 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 orif the landowner(s) is
an indwidual(s), the name(s) of the owner(s) may be listed as the financially responsible parly(ies).
T_CkYy D rAQ 75 `T0 V\S4Y U �An Y►
Company Name �t E-mail Address
0-" CzLV\
Current Mailing Address Current Street Address
9750Z
it State Zip City State Zip
Phone: Office # !?R-WP_7'57 Mobile #
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.
2. (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.
Name of Registered Agent
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City State Zip
Mobile #
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
Current Mailing Address
City State Zip
Phone: Office #
E-mail Address
Current Street Address
City
Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

Telephone Fax Number
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 E-mail Address
Current Malting Address Current Street Address
City State Zip City State Zip
Telephone 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 E-mail Address
Current Mailing Address Current Street Andress
City
Telephone
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 attomey-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.
L V a [_ Ior'j z) N
Type oWi?t name _ / A Title or Authority
2
Date
I, -Mom PC's F. 06-)1�NQ"-'l , a Notary Public of the County of WGX o
State of North Carolina, hereby certify that it. Ta, -'\ a-n ,e1 _ appeared
personally before me this day and being duly sworh acknowledged that the above form was executed
by him.
n
Witness my hand and notarial seal, this _ day of web Ck!a,j ? , 20_13_
14
THOMAS F. CO HHOUN Notary
N - Tf�RY PUBLIC
WA COUNTY, NO My commission expires