NCC233597_FRO Submitted_20231206

FINANCIAL RESPONSIBILITY/OVNEMLIP FBRU
SEDIMENTATION POLLUTION CONTROL Al-Rr'Ti
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 c.moister; 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.)
Part A.
1. Project Name v`ei ZS 4 c>k-k- nit Lo4
2. Location of land-disturbing activity: County CA,Avit - • City or Township Li -
Highway/Street -kv,k • - C 7- Latitude 357:2,,-/-740 tc% Longitude
3. Approximate date land-disturbing activity will commence: eN
4. Purpose of development(residential,commercial, industrial, institutional,
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 so:•-•$900.00).
7. Has an erosion and sediment control plan been filed? Yes_ No
8. Person to contact should erosion and sediment control issues arise during land-distuvbing
Nemec...) - - E-mail Address P ict-c e Act.e.icf ,-,r-zentrfc,wt
Telephone Cell# ID
9. Landowner(s)of Record (attach accompanied page to list additional owners):
sere let+- erritr LI) i!)9 7 Ho /3
Name Telephone Fax Number
Ixe vta r- 1.1" (t)75°I ckci 141 je/
Current Mailing Ads Current Street Address
/ ) 3// Lr
City State Zip City State Zip
aCaC MO,9 C‘ Page No. a (c. Provide a copy di'41F,mos'p,c,mr,Aant doc,c1,
Pan 6.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship,
the name of the owner or manager may be listed as the financially responsible party.
a r7 -PD ftee_cie%As.ltrwe r 1,..n.yr.,‘
Name E-mail Address rrL
et gcd yrket T - L,0 Ynr-e (I--
Current Mailing Address f Current Street Address
ZIA A ao,_ 6,\
Cityamb Up at!
Ste%) Zip
Tz4ephone M6 7- Fax Number _

2. s re 75 r mP r 7 3 J'JaJr�; I ' it �fi-.f ` 1 1 Ja'l _.g(' E ;f 1_ t. and aIv or,f ir1/
��� L .SLu� �U,�aV�t��l��lAi ���e Jt dt,� .� �,� ��.d�. ��t_VS� .J�., �d.l�,(�.��C �uJ�J�i�l,�, �Ju� J�t?„Su<r .i i,ires
of f i--K 10, EG 71 n s' :
Current Mailing a ddress -- — _ �,�u,� �: _ � _ -_ _______ _,
�
City— Q u _ _Zip
�= ___ --____ _..__a-.—tad - __—
ED
(b) if the Fin-ncially Responsible Party is a Paetrerahip or other person engaging in business under en
assumed name, 8i r.-oh a coE y 0f tin Ce IFIcaks 7 Assumed Me . if the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered erit E®read Address
r P ! -ir' S+,-�-" ]r ss Currant. t 3 e
iiTIZ°--- - _— `Dilate- A ty ._ —
are --Zi-p
r:o.p:Dn Fax Darrnbar
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 b+_-: any change in the information provided herein.
P
T �p 'title or Authority
l p (—)- S 7.,t)2
Sign Date
I,, U ff.S5r1e. he/• "14SS , a Notary Public of the County of tAcivr.c _
State of North Carolina, hereby certify that 173 h ACRA, appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal,this �5 day of_ ©(.-t-t b e-f , 20 a
,,„p„n n,n,,,,,
moo` P.-Nµ�ssio p••% - Ana►
O TA ` N:
�� 1\ - Notary
Seal i .__��y - -
-,`,, AUB L I G /0; y corrr�iJosiori expir;s M 01/4 a�
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