NCC233595_FRO Submitted_20231206

FINAWCiAL RESP*IMEOLITY/ObriMEISHOP FORLJ
SEDEMENTATiON POLLUTON C4IVIT.-OL.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 and/
or fax information unavailable,place N/A in the blank.)
Ft A.
1. Propot Nam: v_111 • 1--°-+
2. Location of land-disturbing activity; Canty City or 1=mM/to Li
Highway/Street S-kei. • • cy LAtude Longltude_:7-3 Lt,r3(4,e-f-c--0
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential,commercial, industrial, institutional, etc.): Azia.:6.er‘hbv. /
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): • V7- Pic rc-
6. Amount of fee enclosed: $ 0 . The application fee of$100.00 per acre
(rounded up to the next acre)is assessed without a ceiling amount(Example:8.10 ac=$900.00).
7. Hes an arogion a.,Ad sedlmeN ornkci p been Mad? Y69s Endor.,©d ci(10-
8. Person to contact should erosion and sediment control issues arise during land-elleturbing tctivity:
NamEri trwc.-A-Qvur E-mail Address — fPQ rftc„acn
Telephure_ Cell# tl MC5'°1 2-"61-Fan
9. Landowner(s)of Record(attach accompanied page to list additional oumr,,c-o):
%Je-( yre Ce-etr 10 "1%9 (0 /3
Name Telephone Fax Number
3-dl. MO vAr4t.r ()( )tcti Rci 4e7 Z
Current Mailing Address Current Street Address
4›Net3C_- r)3// r‘ 44,e fN, N)C— 2(1)3 kr(c)
City State Zip City State Zip
10. Deed Book No. C'c‘ Page No. Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Pvc,,e!4r.
comprehensive list of all responsible parties on an attached sheet.)if the company or firm is a sole preparehip,
the name of the owner or manager may be listed as the financially responsible party.
)isYbrWrIr? .:::cterPrD 1)-et_ Le• WW2 rrtc,r p
Name E-mail Address
E9?),:i gas yytt-ei TT- Pvtiext-e7 r 7--
Current Mailing Address I cr 3,reet Address
v „e'
_
va,toZp C:Itc State
TearAwzP _L-4-6 7-"Eoz Number

?. (a) If the Financially Responsible Party is not T rzsIderbt;c,' Xoti-i a lira, OR' no a End 3(zMC ;,C.Uc
of the designated North Carolina Agent
Current t Mailing i d s C e `x ' e sCittY State Zip r::ft, State<.
Zip
T epep€ or _ _ _____—,._-..�_, EI Nurn p r<- —__� ,_._.„,__ -�� ,_.
'7,L)) 51(-, Pm-r.. !Fly Responsible Party is a Partnershi. or other person engaging in business under an
sor ), ? r "ti. , acaach a copy e fshe CarMmto o7 Asou, a i, Ma =Ro. If the Financially Responsible
'Cliff L J c, V , i ration,give name and street address of the Registered Agent.
Name of Registered Agent E-mail Address
eurrzils a i Eking MdF3ss 00. aa`•r Set Acidseat
erg State Zip S 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.
c4:t:5-v-o..,A----Q.ri I� .�?--,D M rg n n(lem b2 --
or print name Titre or A ty
/\- / M -zap
s' naire Dated ` 3_
I, a Sri . V44) „mP , a Notary Public of the County of r.1 ,da_.
State of North Carolina, hereby certify that -Son c,A.aV1 V appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness myhand and notarial seat this
� day© © b.er �,n ������) _��
Seal _ _ '
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