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HomeMy WebLinkAboutNCC230828_FRO Submitted_20230329FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone number is unavailable, place NIA in the blank.) Part A. 1. Project Name RIVERSTONE (LOT #3) 2. Location of land -disturbing activity: County RUTHERFORD City or Township HIGH SHOALS BROAD RIVER BLVD 35.21518-81.84418 Highway/Street Latltude(decima�degrees) Lorig itude{decimaldegrees) 3. Approximate date land -disturbing activity will commence: ASAP 4. Purpose of development (residential, commercial, industrial, institutional, etc.): COMMERCIAL 5_ Total acreage disturbed or uncovered (including off -site morrow and waste areas): 8.94 ACERS 6. Amount of fee enclosed: $ 900 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 $940). Checks should be addressed to NCDEQ. 7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 0 No ❑ 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name LUCAS TOLLEY E-mail Address Lucas@odomengineering.com Phone: office # 528-247-4495 Mobile # 828-289-4790 9. Landowner(s) of Record (attach accompanied page to list additional owners): RIVERSTONE 3 LLC Name 10620 TREENA ST Phone: Office # 10620 TREENA ST 619-696-7355 Mobile # Current Mailing Address Current Street Address SAN DIEGO CA 92131 SAN DIEGO CA 92131 City State Zip City State Zip 10. Deed Book No. 2051 Page No. 1971 Provide a copy of the most current deed. Part B. 9. 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 or if the landowner(s) is an individual(s), the names) of the owner(s) may be fisted as the financially responsible party(ies). RIVERSTONE 3 LLC Company Name 10620 TREENA ST Current Mailing Address SAN DIEGO CA 92131 btabb aaenvdev.com E-mail Address 10620 TREENA ST Current Street Address SAN DIEGO CA 92131 City State Zip City State Zip Phone: Office # Mobile # 619-696-7355 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 E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office # 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: Corporation Service Company Name of Registered Agent 2626 Glenwood Avenue Suite 550 Current Mailing Address Raleigh NC 27608 City State Zip Phone: Office # E-mail Address 2626 Glenwood Avenue Suite 55 Current Street Address Raleigh NC 27608 City State Zip Mobile # 302-232-3737 Name of Individual to Contact (if Registered Agent is a company) (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. Bruce Tabb Type or print name Signature owner Title or Authority 1211122 Date a Notary Public of the County of State of North Carolina, hereby certify that _ _ _1��Y_ �L�, appeared personally before me this day and being duly sworn acknowledged thawwabove form was executed by him/her. Witness my hand and notarial seal, this I day of 20_ z No B S"ott Roach PUBLIC My commission expires d County, NC L""L ComrExpires ,tune 08, 2026