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Home My WebLink AboutNCC232538_FRO Submitted_20230829 ^ - Check if this project isARFA+fuxded 0 . ' FINANCIAL RESPONSIBILITY/OWNERSHIP FORM SEDIMENTATION POLLUTION CONTROL ACT No person may initiate any land-disturbing activity on one or more acres ao covered by the Act, including any activity under o common plan of development of this size as covered by the NCGO1 pemmit, before this form and an acceptable erosion and sedimentation control plan have been completed and approved by the Land Quality Section, N.C. Deportment of Environmental C>um{dv. 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 b|onk.) Part A. K�� l��|1 � HILL RENTALS 1. Pn�en�Nanme`"'~^" ^' ~^^-^- ' ""-^- *If this project involves American Rescue Plan Ad (4RPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure(DWI). ��J��| /�� j��[��{]�\/�i�� 2. Location of land-disturbing activity: Counb/~^^"~^`-��"" City orTownship hJ��u�� 1 1 1'� 34ru59O1 '77504275 Highvvoy/Streo{'"��^�" ~ ' ' '^^ La�itudew�/�°/u°m=°* ' Long�udaw"u��mw=s> � �� 3. Approximate date land-disturbing activity vviUoommnenoe: ~^ `^^ ^�°"~^^ 4. Purpose of development(naoidmnba|. commercial, industrial, institutional, et .): RESkDENTYA- S. Total acreage disturbed or uncovered (including off-site borrow and waste areas):3.1 � G. Amount of fee andooed: $^1-`~'"��'�l=^^ The application fee of$1OO.UO per acre(rounded upto the next acre) io assessed without o ceiling amount (Emamp!e: 8.1O-oore application fee is$AUU). Checks should be addressed toNCDEO. 7. Has an erosion and sediment control pion been filed? Yes Mx Enclosed [] No F-1 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: ��J | �}�� T�� 8 Nonme��` "° " L. PIERCE^~°^- �-mail - ^ ` ` ~^x��"-" ""^~'~°~�`,' C�1��O�� 01� Phone: Office � '=`^-�~^"^^°~ Mobile `^ ^=^'"=�� ^° 9. Landowner(s) of Record (attach accompanied page to list additional owners): [}O[1B[E R FARM SER\/ICE, LLC 9103890775 Noma Phone: O#ima# yNobi|e# 1155 HAWS RUN ROAD 1155 HAWS RQhJ ROAD Current Mailing Address Current Street Address MAPLE^_^- HILL, NC 28454 MAPLE^_.- HILL, NC 28454 City State Zip City State Zip ��R� �� 10. Deed Book No°-`°`� PageNo. ' ~^`^ Provide a copy of the most current deed. , ^ PartB' 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). JAMES E^ S1| ANCE 'am'e's'}a[lceaOma^|'cC>m Company Name E-mail Address 566 HAWS RNhJ ROAD 566 HAWS RUN ROAD Current Mailing Address Current Street Address JA��JV�| 1 �� 0(� ��1O ]Z�(�{��yJ\�|| | �� J�� '1� - - - '___-' . -_ ___ .- -' '.~^ .-~`~. . . .^-._^_, . ..~ ^_~~.`^ City State Zip city State Zip C��O_��~&��O Phone: ��oe# � ' = ��= �' °� Mobile# Nobs: 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 bo 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 Offina# Mobile# Name of Individual ho Contact(if Registered Agent ieacompany) (b) if the Financially Responsible Party is not a resident of North Carolina, give name and street address mf 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 Qh/ State Zip city State Zip Phone: Office# Mobile# Name of Individual bo Contact(if Registered Agent is moompany) (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. James E. Silance Purchaser Type o rint name , Title or Authority • N.Y.. 7/4; ure Date I, 2Q YL . i" I ( , a Notary Public of the County of Qfs State of North Carolina, hereby certify that lance__ 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 a8"day of IMO.Y'GIR , 20 o3 `>ottsi11/!///_ njubkrIaL V), a � �\P•EE R �'/��'�, Notary I:( �°T4 . My commission expires /6 0 to ��''• , 1•�0.24 26 .•'�_�� 0,6v tout% ``�. . ` Continued from Items y & 10 /h Part Aof the Financial ResponsibilitylOwnership Form for multiple owners. Attach copies of this page aoneeded to list all landowners. Landowner 2cfRecord: Name Phone: OOioe# Mobile# Current Mailing Address Current Street Address city Gtoba Zip city State Zip Deed Book No. Page No. Provide o copy of the most current deed. Landowner 3cfRecord: Name Phone: Ofhca# Mobile# Current Mailing Address Current Street Address City State Zip city State Zip Deed Book No. Page No. Provide o copy of the most current deed. Landowner 4ofRecord: Name Phone: C>#iue# YWobi|e# 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 5ofRecord: 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 Yin Part 8of the Financial ResponsibilitylOwnership Form for multiple Attach copies of this page mo needed h/list all finanoia8vresponsible parties. Company 2Name E-mail Address Current Mailing Address Current Street Address city State Zip City State Zip Phone: [>ffioe# Mobile# Company Name E-mail Address Current Mailing Address Current Street Address City 8bde Zip City State Zip Phone: Office# KAobi|e# Company 4Name E-mail Address Current Mailing Address Current Street Address city State Zip city State Zip Phone: OfUoa# Mobile# Company 5Name E-mail Address Currant Mailing Address Current Street Address City State Zip city State Zip Phone Dffiom# Mobile#