NCC230732_FRO Submitted_20230322

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by t. ,.�V
and an acceptable erosion and sedimentation control plan have been completed and
Quality Section, N.C. Department of Environmental Quality. Submit the completed fo �6\(-
Regional Office. (Please type or print and, if the question is not applicable or the e-n
number is unavailable, place NIA in the blank.)
Part A.
1. Project Name
2. Location of land -disturbing activity: County P, _ City or Township I nj u
Highway/Street 5) h,atu-e Rel . Latitude(decimal degreesa, h/S3 Longltude(decimal degrees) fa. oq
3. Approximate date land -disturbing activity will commence: alU
4. Purpose of development (residential, commercial, industrial, institutional, etc.):_ Rr-S'irle-k -7 &L,/ �rrm.j
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
6. Amount of fee enclosed: $ 906- 00 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes inclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 4 gym[ �c�c � It E-mail Address _ Cr_ '. [ j ,4 5 w►[ Cam_ CU=,1 .40 YVI
Phone: Office* �(o�� gt�i — 1(0�� Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
aC%-MX 5 a �G� a� D_ LO`1 —Did - `P 3 J G•Y1r+G
Name Phone: Office # Mobile #
hlb G,t+`,S�o�0 rr� ��. C,rnc.
Current Mailing Add ess Current Street Address
e&M06hel [D CSC a93aa 5a4,v_ & c
City State Zip City State Zip
10, Deed Book No. _ 4_71 Page No. 103 Provide a copy of the most current deed.
DE 0 7
AND QUALIT Y S CTO
ASFlPIII 1 ;7-.

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 isa sole proprietorship orif the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible parfy(ies).
Tn-nie—S 4- IA611u Cer r—'Tr CS41 } i $c>>�►e C4-0 Co
Company Name 9cc]] E-mail Address
IM1t~► �� l� b �nc� b1 GA . 6 A m C
Current Mailing Addr ss Current Street Address
City I State Zip City State Zip
Phone: Office # 11,o2j , Mobile # sG-_yne-
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:
/Q A Mr
Name of Registered Agent E-mail Address
W Na
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # �) /I Mobile # lui
Aj6
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:
L'i 4.. L (Oct,S 1)rr':5brit _T K -
Name of egistered Agent E-mail Addre s
Current Mailing Address Current Street Address
4 as . s54DL%c
City State Zip City State Zip
Phone: Office # - ��v(��� � Mobile # 154_ty«-
RECEIVED
K
Name of Individual to Contact (if Registered Agent is a company) -AND QUALITY SECTIor
ASHR/11 I F

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
j!
Type or print name / Title or Authority
12�L�Ika d �
Si n tur Date
vj-OA
State of North Carolina, hereby certify that
before me this day and being duly sworn a
Witness my hand and notarial seal, this
Brad Rawson
aMM MEIMS
a Notary Public of the County of
n f 1 /1 n _
.� day of _
tha�iha /_ 1�45 �4�lappeaed personally
he above form as executed by him/her.
, 202--
Notary
My commission expires //.�
L4ND QUALItY S �r1�F,
ASHFi/111