SW4090301_Sediment Pollution Form_20090323

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 Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place NIA in the blank.)
Part A.
1. Project Name McDONALD' S South Main St. King, NC
2. Location of land -disturbing activity: County Stokes City or Township King
Highway/Street S - Main St. Latitude 3 6deg15 ' 4 2 " Longitude 8 0deg21 ' 4 8 "
3. Approximate date land -disturbing activity will commence: ASAP
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.26
6. Amount of fee enclosed: $ 130 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Persontocontact should erosion and sediment control issues arise during
rland-disturbing
�activity: +
Name C. tni l �f � E-mail Address Gil q }. I�DT�L.1r�C.11.1 t LU Us • Y1i - cc m
Telephonevlt_9 Cell # g1j_1l4D tp 1Be Fax#t 3214ZI5
9. Landowner(s) of Record (attach accompanied page to list additional owners):
C mN �i- T(setcrmw
Name Telephone Fax Number
�D.4X 1154
Current Mailing Address Current Street Address
ri'I i - VAOUXl 1r1C 1
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
D.3.399-Pg.157 and D.13.580-P9.792
Part B.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
0cDDTcdd'5 bTw- �x.
Name E-mail Address
av OtD"4 d 15 ,i ozA_
Current Mailing Address Current Street Address
$ron -rL ��23
City I State Zip City State Zip
Telephone (PW [ 2-� 5WID Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Me�VM14 `'4) U5A- 4LG
Name E-mail Address
six ka. �2tXD
Current Mailing Address
'Al ac, 2 0
Ci y U Stak Zip
Telephone l�
Current Street Address
City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, 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
Telephone Fax Number
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
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 Person). I agree to provide
corrected information should there be any change in the information provided herein.
e-JaCUN, �&nl - Rt4 11W CM6 +u fn r
Type or prin name Titl Authority
Signature Date
I, J_ajr Li n -Ooo a Notary Public of the County of
�I
State of North Carolina, hereby certify that C der appeared
personally before me this day and being duly sworn acknowledcled that the above form was
executed by him.
Witness my har)o and notarial seal, this da
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N:T)WI
Ser
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of
20 oQ .
Notary j /� f
My-c mmission expires U 2�zr2��