NCC231338_FRO Submitted_20230523

NC Department of
Check if this projegi"iMcellec►talQU�ty
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM MAR 2 7 2023
SEDIMENTATION POLLUTION CONTROL ACT
Winston-Salem
No person may initiate any land-disturbing activity on one or more acres as covered by thittegibipailttik2 any
activity under a common plan of development of this size as covered by the NCG01 permit, before his brm
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 N/A in the blank.) 2
Part A. r1U4 — 023 -d5(
1. Project Name aPP� '?ly Fij- f3 uj5 R d
*If this project involves American 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 DotVklJc+'l City or Township Cl till PPIW1.5
Highway/Street Fry., e i I AA, Latitude(decimal degrees) Longitude(decimel degrees)
3. Approximate date land-disturbing activity will commence: ' V r —2_ 1._
4. Purpose of development (residential, commercial, industrial, institutional, etc.): R e I I Grp (
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4
6. Amount of fee enclosed: $ ( li $. . 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 ❑ Enclosed Ili No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name T ..,,�fit 0114S E-mail Address Scam al 1 ePl j' t v.
C�m
Phone: Office#I?22 229/ Mobile#J3 _31/ 7 —
9. Landowner(s) of Record (attach accompanied page to list additional owners):
�v h °7r 3 d7.7 G it -gi77.7
Name Phone: Office# Mobile #
'/4g 0014h d4I L 0 r; Yt„ WS Zeal,Mc- Or, y4,
Current Mailing Address Current Street Address
j A ( 41?7/ 41 WJi - 'R- . rI/d��
City State Zip City State Zip
10. Deed Book No. ei Page No. I "7 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 or if the landowner(s)is
an individual(s), the name(s) of the owner(s)maybe listed as the financially responsible party(ies).
r.
6 n n CJ tt" rG4 I n 0. r,M,i 0';a; ,/�(.QI 1*7" . (,�n-)
ompany Namei ail Address
/'a Ili 14VI dol C.. OK f-t., we 1eosi dAit DK'c
Current Mailing Address Current Street Address
WI n-54IYr� Glerv$ 1k- 2 r7'10`V Of b ,,9 k s1 ' 4Ic,n it,IC... .. 7'7/cy
City State Zip ity State Zip
Phone: Office#Y3� 6 '71—,3Z7l Mobile# 3iv -6'71 -32-1I'7
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:
r.
(JO �lc..J tit/Ana/xi( InL= OkrlfY)Co4's'1'ia-Kk(911C-MwA, .
Name of Registered Agent E rr ail Address
Current Mailing Address Current Street Address
1 ,.
1,1 I;fisltd..)-S:ell erii /tic- 2_7/6 4 k\f,,,,s1-6e,...jkitm Ai(..... e2'7/ 'j
City State Zip ity State Zip
Phone: Office#2-314 ._C/ 7/ ".4'7'7 Mobile# Sill - (; 7/—.Si-`7'7
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 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)

(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.
(1 01A, Pal
pe or p r t name Title or Authority
�e Date .3A7 `7140-U
/ 9 /' , L. , a Notary Public of the County of
State of North Carolina, hereby certify that ())Liit 1Z appeared personally
before me this day and being duly sworn ack,.wledged that the above form was executed by him/her.
Witness my hand and notarial seal, this o2? day of ( 14'44'it , 20,23
i:eAit;e717,0/L)
Notary
Seal 9)
My commission expires
PATRICIA F. KIRKMAN
Notary Public- North Carolina >
Forsyth County