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Home My WebLink AboutNCC231988_FRO Submitted_20230628 Check if this project is ARPA-funded ❑ Attach a copy of the Lepdf FINANCIAL RESPONSIBILITY/OWNERSHIP FORM c4vEd+ega13, j!i SEDIMENTATION POLLUTION CONTROL ACT MAY 1 6 2023 No person may initiate any land-disturbing activity on one or more acres as covered IMi,Ac�t,cin luding any activity under a common plan of development of this size as covered by the NCGO1,perinft, elate is form and an acceptable erosion and sedimentation control plan have been completed anbilASMbeiffidcdrie 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. J/O'ID f2O23—Neff ,p 1. Project Name � P�t Ot Sit, 3a30 'Be} SQA FOI *If this project involves American Rescue Plan Act(ARPA) funds, list the Project Name or Project Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County UwidStrr1►-� City or Township Lex VIA-kor1'►� Highway/Street �-{ �I. LatitUde(decimal degrees)35% W/t0ongitUde(decimal degrees) �3 '2I 240 3. Approximate date land-disturbing activity will commence: D 4. Purpose of development(residential, commercial, industrial, institutional, etc.): hes i ;4v1 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 113 ()Jig 6. Amount of fee enclosed: $ ZOO'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 ❑ Enclosed g No ❑ 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name Edfall tSS1lk E-mail Address b✓obvo33loelwlr,:;1.CO.1% Phone: Office# 'vQ Mobile# C36) 225-21 f0e 9. Landowner(s) of Record (attach accompanied page to list additional owners): tfodti ESSi dt NA (33(!)22-5.-2,1 Name Phone: Office# Mobile# 4°41 Arnold Rat y0011 Avviola Pspi. Current Mailing Address Current Street Address IAxiv)yfvn NC 272q5- itAX413 kvk IJC z7zis. City State Zip City State Zip 10. Deed Book No. Wg iiiir Page No. tar >i-Provide a copy of the most current deed. Vi33 1 31z 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)may be listed as the financially responsible party(ies). odd E ss c c 'b1(ob✓v 331a D e5 vicvi r .mow. Company Name E-mail Address Loy( 4vv,ld 124. yo41 Av.ioIcl gal. Current Mailing Address Current Street Address L l ,,, tJc 2.7z L9-rity % 27w— City State Zip City State Zip Phone: Office# `rA Mobile# e 3ti) 2 ZS'Zg BC� 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: /4 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: 14 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. 130ro& ESs i c,k- Typ—r print name Title or Authority IAIP ' � l. % 5/ 'Jr/7V ignatur. Date I, L 6_kk.re;L:3" _ 1)ctr) 1 e I , a Notary Public of the County of �cw,kA-5L State of North Carolina, hereby certify that /,: e appeared personally before me this day and being duly sworn ack owledgediat the above for as executed by him/her. Witness my hand and notarial seal, this 1 day of a 3--. ' a , 20 Q , LAURA P McDANIEL o ary NOTARY PUBLIC 0 / tatia A DAVIDSON COUNTY,NC My commission expires (� My Commission Expires 6 4-2025 662 , aay4p ieuol2aH wales-uoisU fv a 925- CZOZ 9 I AvW paniapaa Alen° inuawuoainu3 to 4uawpedaG D N Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: Ni Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 3 of Record: N I 4 Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 4 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Landowner 5 of Record: Name Phone: Office# Mobile# Current Mailing Address Current Street Address City State Zip City State Zip Deed Book No. Page No. Provide a copy of the most current deed. Continued from Item I in Part B of the Financial Responsibility/Ownership Form for multiple parties. Attach copies of this page as needed to list all financially responsible parties. 1V Company 2 Na114" a E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# N/I4 Company 3 Name E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# Nj4 Company 4 Ne E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# 1,•lit\-- Company 5 ame E-mail Address Current Mailing Address Current Street Address City State Zip City State Zip Phone: Office# Mobile# rs.