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HomeMy WebLinkAboutNCC231545_FRO Submitted_20230522 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 and/ or fax information unavailable, place N/A in the blank.) P1.art AProject Name SRI THREE - RV PARK & CAMPGROUND PHASE II 2. Location of land-disturbing activity: County CLEVELAND City or Township BOILING SPRINGS Highway/Street OFF 150 TOWARDS GAFFNEY,SC Latitude 35.1981 Longitude-8 1 '6628 3. Approximate date land-disturbing activity will commence: Upon approval 4. Purpose of development(residential, commercial, industrial, institutional, etc.):RECREATIONAL 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 6.67 AC 6. Amount of fee enclosed: $700 . The application fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$585). 7. Has an erosion and sediment control plan been filed? Yes No Enclosed X 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name SCOTT ROACH E-mail Address scott@odomengineering.com Telephone 828-247-4495 Cell# 828-289-6047 Fax# 828-247-4498 9. Landowner(s)of Record (attach accompanied page to list additional owners): SRI THREE, LLC 704-477-1405 N/A Name Telephone Fax Number PO BOX 1600 225 BRENT HALL CT Current Mailing Address Current Street Address MATTHEWS NC 28106 CHARLOTTE NC 28270 City State Zip City State Zip 10. Deed Book No. 1830 Page No.593-595 Provide a copy of the most current deed. Part B. 1. Company(ies) 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 sole proprietorship, the name of the owner or manager may be listed as the financially responsible party. SRI THREE, LLC tyler@studentrental.net Name E-mail Address PO BOX 1600 225 BRENT HALL CT Current Mailing Address Current Street Address MATTHEWS NC 28106 CHARLOTTE NC 28270 City State Zip City State Zip Telephone 704-477-1405 Fax Number N/A 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 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 Party is a Corporation, give name and street address of the Registered Agent: George Joseph Selembo Jr. tyler@studentrental.net Name of Registered Agent E-mail Address PO BOX 1600 225 BRENT HALL CT Current Mailing Address Current Street Address CHARLOTTE NC 28106 CHARLOTTE NC 28270 City State Zip City State Zip Telephone 704-477-1405 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. George Joseph Selembo Jr. PRESIDENT Ty.,- or print name Title or Authority - � fir +- 17- 0- Signature Date I, . .. SGo-FvAe-* , a Notary Public of the County of Z111Efe--a_P State of North Carolina, hereby certify that appeared personally before me this day and being duly sworn acknowledged that/the above form was executed by him. r-�V Witness my hand and notarial seal, this I l''day of 1 V , 20 B Scott Roach NOTARY PUBLIC __ Rutherford County, NC Nota My Commissio6E0ires June 08,2026 71 �-4L My commission expires tykf ,, )- 124*