NCC230656_FRO Submitted_20230310

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 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 andfor fax Information
unavailable, place NIA in the blank.)
Part A.
1. Project Name Bf-"S-Ay Come e k /'V• l �zf Oi
IF 2. Location of land -disturbing activity: County 1 '1 &17ell City or Township ''��'e �',�� L
,
Highway/Street ly2— W�I4n/`Q �L'{atitude g5� � qSrr Longitude e2,p V-7/-1 rr
3. Approximate date land -disturbing activity will commence: - 'orac J
4. Purpose of developmerd (residentia coercial, dustrial, Institutional, etc.): 4'�Crr?1� �'! I�i s�7 �'
mm
b. Total acreage disturbed or uncovered (Including off site borrow and waste areas): J; � 33
dJe
& Amount of fee enclosed: The application fee of $100.OD per acre (rounded
up to the next acre) Is assessed without a ceffing amount (Example: 8.110-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
i -P -- --- E-mail Address, / /� (i j
Name ��''►� , �facuS'S ►^�-1; , r�
Telephone-, k P I `2-9 2—lr93: Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Telephone Fax Number
Current Mailing Address Current Street Address
77 7
Ci State Zip City State Zip
10. Deed Boole No. Page No. 2,1 Provide a copy of the most current deed.
Part B.
Company (les) 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 sale
proprietorship the name of the owner or manager may be listed as the financially responsible party.
Name E-mail Address
ire �d • ... y?- / r✓
Current Mailing Address Current Street Address
ity state Zip City Sfate. Zip

Telephone'F?3 _70K__ 2-899 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:
All*
Name E-mail Address
Current Mailing 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 Marty
is a Corporation. give name and street address of the Registered Agent:
Name of Regi tered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 in�ff ormabon provided herein.
Typs ame Title or Authority
S14,nalure Date
, a Notary Public of the County of
State of North Carolina, hereby certify that V) _ - appeared
personally before me this clay and being duly sworn acknowledged that the above farm was executed
by him.
Witness my hand and notarial seat, this ) L day of ZO F�
`���:�ul�ifyi
p r,,TARy ota
ig Seal
Ir.,c '°LB~ .�My commission expires
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