NCC233117_FRO Submitted_20231018

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 N/A in the blank.)
Part A. e
1. Project Name /J e( / ^,� ?r/, e9 .
2. Location of land-disturbing activity: County/ ' City or Township / !f/4 0
Highway/Street, `jA/r/d Latitude 35./ Longitude - O- 6(f'
3. Approximate date land-disturbing activity will commence: /�/-2 V..2(.2.2
4. Purpose of development(residential, commercial, industrial, institutional, etc.): r%Jd / /f
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): a g
6. Amount of fee enclosed: $ . 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 if No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name_C A�✓ 626,/7ik,63690 / 'E-mail Address %"!C (0"r 'f✓ .c
Telephone Cell#71C,�-/%3"'7 (V_ Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
e j / V, 0///1t e c 6c�- 6 88--.1-b
Name Telephone Fax Number
3.�35 ' iu aka) J335 .///r�. ,m a/'�h., .*'--
Current Maili Address Current Street Actress
#//17/4/7 Alf! . g-2727? 74/f/w
e zf.,,:-, -
City State Zip City State Zip
10. Deed Book No. ?p 3 3 2 Page No. 9a Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
omprehensive list of all responsible parties on an attached she t):
la s,o-pX cr. ,0„ ,1//-).a7L;Al 7 9
pki, /A/(9)7x,/v - 6- 2.--7
Nam mail Address
932-S 67,an ( ,,r2 . , _?. #47,47,/ a/e7,2/2 2 (Current MailirVAddress Current Street AdizketS
//%2VfilV;i0-2 .2 z`-)2,1 7 //i&i////f le .• (S).-2-2 7
City State Zip City State Zip
Telephone C5 8 ~ 6 8 8- J 0 1 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
,_.) , t,/ 'AI-7 _ /id' aKil/e,,,--i--
Typ r int name Title or Authority
///,/- .7075
nature Date
ci
1
I, `t A LA O LP tVO V, a Notary Public of the County of le-e/c1-/ i
State of North Carolina, hereby certify that -- JOS . d v , O/co45i v I appeared
personally before me this day and being duly swo►'n acknowledged that the above form was
executed by him. s J
Witness my hand and notarial seal, this f . day of O IC'k , 20 1
J .o�0s �.F. OG=
• Notary
• �:°NOTARV� : =
Seal
s , PubLIC 2 My commission expires -,_1 f t 6f1 - "
%4:44/RG;°