NCC233366_FRO Submitted_20231113

Cheek if this project ARPA-lunded
Attach a copy of um!ettatr of/ntont to Fund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initrate any land-disturbing activity on one or more acres as covered by the Act, :ncluding any
activity under a common plan at development of this size as covered by the NCG01 permit before this form
and an acceptable erasion 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 pnnt 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 Q ( 8 el 5 I r G
'/I th1 G pnlje f tnt,O V3 Ankinami Reso a f lert Ac; (ARPA) fun*, NV the h';v oct Fd,.,rrn:ut Plq�dCt
Number Ie.g. SRP D ARP.0121) Wow unctr which}Ow wore approved fix funding through the
D&rarlru:ref Miter Infrastructure](AWW)
2 Location of larva-disturbing activity- County la la %r44.' City or Township ( C7 1 1)t C/
s..)53c47
H igrtway Street '/ 5 //alit) LatituOtow.ideveam Longitudeaiwans n,trios t%,.5ti'1,1 7
P c h
3 Approximate date land-disturbing activity will commence _ _
4, Purpose of development (residential, commercial, industrial. institutional, etc.):?it,'1 a' dt ii"Ir r?
5 Total acreage disturber or uncovered(including off-site borrow and waste areas): I. ,
6 Amount of tee enclosed $ 3 I'£' . 0'o The application fee of S100 00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 6 10-acre application fee is $9fX
Checks should be addressed to NCDFC
7 Has an erosion and sediment Control plan been filed? Yea eEnclosed E No L
8. Person to oontact should rirotion and sediment control issues arise during land-disturbing activity
Name eve4 t.,- E-mail Address •I 1 e✓Z4 5 ft e lyfi?r.Z e rl'i
Phone Office* Mobik# 7 t'y- 70. t' iqeG,
9. Landownet(s)of Record (attach accompanied page to list additional owners):
e Pit _ S {
Name Phone' Office* Mobile it
Current Mailing Address Current Street Address
*3-1) 75
City State 7ip City State Zip
10, Deed Book No. / E 7 7-5-
_ Page No C / &? Provide 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 yuld pro,onsvrorship or if the land wner(s)is
en uutiv,Vual(s), the n*nefs)of the ownen's)may be bsied es the*Pencil*respons be perfyfes).
S-
AC✓ co 54es s- 744,4, 1 �tJs� '/ij�9'd , I.e
Company Name Email Address
/Y/ ?' Alfo,rs 1tee d
Current Mailing Address Current Street Address
tri A/. (
City State Zip City State Zip
Phone: Office# ?D i/- mobile a
Note- If the Financially Responsible Party is not the owner of the land to be disturbed, include w,th this form
the landowner's signed and dated written consent far the applicant to subrrrit a draft erosion end sedimentation
control plan and to 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: Office rt Mobile ft
Name of Individual to Contact(if flegistered Agent is a oompany)
(b) If the Financially Responsible Party Is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry-
Name of Registered Agent E-mad Address
Current Mailing Address Current Strout Address
City State Zip City State Zip
Phone- Office# Mobile#
Name of Individual to Contact of Registered Agent is a company)

(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 regisierod and doing business under an assumed name,attach a copy
of the Certificate of Assumed Name.
Company 08A Name
The above information la 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.
51e...'91 e C'4.?, e
Type or print name Title or Authority
Signature Date
I. gis c f e 4e Qv.1 . a Notary Public of the County of la ALI
State of North Carolina, hereby certify that 5i f t,'i\ S#Q►,.k_ 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 2404N day of Ail;St- , 20 2.3
s1ACsC ltEAv+TT Notary
4 ) ,/o 4
_ $,ge,fJ; . Noah C�':.S�n�
�lrr Noy y..1Fadeu County k 1a2.5
L` My Cor�mtae.oa rtr0`ros My commission expires /vp✓c Mbc(-
1 .. ._ November 01,2025