NCC232637_FRO Submitted_20230831

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.1. Project Name 6voo\&fLL
1C is sr di On Li
2. Location of land disturbing activity: County 1 City or Township �1f} V'U l 11e
cut
Highway/Street Latele LAID Latitude(decimal degrees) Longitude(decimal degrees)
3. Approximate date land-disturbing activity will commence: 1\51\13
4. Purpose of development(residential, commercial, industrial, institutional, etc.):_ 3...tSI dt ,i4i ct-
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed: $ . 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 Q' Enclosed O No ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name U.31 k\ \INuAr E-mail Address �l ki 1441n 021ene5 goof I . Coat
Phone: Office# Mobile# 2-S1-€ 20V `1 j2
9. Landowner(s) of Record (attach accompanied page to list additional owners):
1k"
Name Phone: Office# Mobile#
Q o '60x coo(a
Current Mailing Address Current Street Address
)rceil VI lie, Mc, fl 3y _
City State Zip City State Zip
10. Deed Book No. 351 3 Page No. SL2- Provide a copy of the most current deed.

(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.
W% VI am 0 . 4kInt 1 OW1nv(
T(jjLC ,
or print name Title or Authority
-- t_b_vo
Signature Da e
I, \Jcg(cp R1r,f ( , a Notary Public of the County of pi-4
State of North Carolina, hereby certify that v v I I Q 0.r\ p' Ku. fl t 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 21O day of u I\I , 20 1,3
JOGINA RUSSELL
NOTARY PUBLIC 'fi=; N to RuSee l '
sa
North Pitt County iI
My Commission xpi Carolina
�2�2Q2� My commission expires