NCC232045_FRO Submitted_20230711

Check if this project is ARPA-funded ❑
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, including any
activity under a common plan of development of this size as covered by the NCGO1 permit, 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 N/A in
the blank.)
Part A.
1. Project Name l "e` F l V C1�--- i�l}i✓ 14'7 t1. 0 J i VL /OF ficEOZ3
*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 aA'/` I' J\ City or Township ur vv i l tei
273:21-7-
Highway/Street t t'i ` t.t =' t i LatltUde(decimai degrees) c) t' • • -dLongitude(decimai degrees) 2-
3. Approximate date land-disturbing activity will commence: te.,t 1 77--;
4. Purpose of development(residential, commercial, industrial, institutional, etc.): 1 V ``7Q1.1-E
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2 . O �(� 5
6. Amount of fee enclosed: $ 30 . 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 ❑ No 01
1Z,eV vS i 040 1A P P S tpA nTEO
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: p01619
Name J` `,' )`J E-mail Address D`1pe''710>�`ir'h b ttia0 ovv�
Phone: Office#
)` ° Mobile# 7 i20 1
9. Landowner(s)of Record (attach accompanied page to list additional ownneprs):1-1
y 6
n v)
07-(
Nar4 Phone: Office# Mobile#
Fr) tc7A-, 441
Current Mailing Address Current Street Address
50(2--1 (. iLtit IN) :.
City State Zip City State Zip
10. Deed Book No. '' f Page No. 3 E---1Provide 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 tholandownor(s)is
aninoYvidue/(s). the namouVof the owmor($may be listed ao the finanoia0yresponsible porty«o*.
f~rf�ey-` � V7
J °�t�C��[�.~,
ompenyName ` E-mail)kddnaan �
Current Mailing Address Current Street Address
( N� � C~�
| /��M���� *v� �� 7 /'4
City State Zip City State Zip
�I ^7�'� ~` � / i /7A/7 i
Phone: Office Mobile �7 ^�L/ ^ /~��^� ~ i/V
Note: |f the Financially Responsible Party ionot the owner of the land tobe 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 toconduct the anticipated land disturbing activity.
2. (a) |f 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:
J--
Name ofR�gisteredAgent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Offiue# Mobile#
Name of Individual to Contact(if Registered Agent ioacompany)
(b) If the Financially Responsible Party is not o resident of North Covn|ina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name ofRgminteredAgent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Offioe# Mobile#
Name of Individual tn Contact(if Registered Agent ioacompany)

�
(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
pf the CerUffi tmofAaaunmedName.
companyuu* 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 individua|, by an officer, direotor, pertner, or registered agent with
the authority to execute instruments for the Financially Responsible Party). ( agree to provide
corrected information shou|dthwve be any chaqge in the information provided herein.
revi��
Tv ?� tn@m� or Authority
_� ^�
11�4� �� =// _ �_��
/ -_ ``
S�g�� Date
| � . e Notary Public of the County of
Ile
State of North Carolina, hereby certify thatK�--~(~ ��/*�« ������ b appeared personally
before nne this day and being duly sworn mohn�w|edgmdthat the above form was executed byhinn/her.
Witness nny hand and notarial seal, � � ., _ day of . 20
9
otary
KAvoonnionionoxp| ^�_'
rn "
"

(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-infact, 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.
\\.7 L., , • , ,-
i -
Type or prin‘name ( Title or Authority
igreature Date
1, ,DAtitti___LL'ic, r•v.01- kd____________, a Notary Public of the County of_%•01.9 :62.1______
State of North Carolina, hereby certify that 5‘11 V3 PAP-1 Lev-4 1: appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
WitneSs my hand and notarial seal,this 1_j___day of_M___2__k_n_,_________, 20 -
________
My commission expires ___, _e4A1 1Y 2i,VP
to t\10.5 k4 CA'
SIKCC--
__ _