NCC240163_FRO Submitted_20240118

Check If this project Is ARPA-funded 0
Attach a copy of the Letter of intent to Fund
FINANCIAL RESPONSIBILITYIOwNERSHIR FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may Initiate any land-disturbing activity on one or more acres as covered by the Act, Including any
activity under a common plan of development of this size as covered by the NCG01 permit, 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 address or phone
number Is unavailable, place N/A in the.blank.)
Part A.
1. Project Name SkkI\ ' Lof 5
1
*If this project involves Amer/can Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP- ARP-0121)below under which you were approved for funding through the
Division of Wafer infrastructure(DINT).
2. Location of land-disturbing activity; County- -�-.City or Township Gir 04"-Ci-k (17:Als
Highway/Street .Col 4,,S 1Q„e. }( 1 . Latitude(decimal degrees)353 I Long itude(deeimar degrees)—Tf 1.S T T
3. Approximate date land-dicvity will commence: _b ?.29
4. Purpose of development commercial,industrial,.institutional, etc.): t (A V1,b AA-C
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 8 J
6. Amount of fee enclosed: $ j 0 0 . The application fee of$100.00 per acre(rounded
up to the next acre)Is assessed without a ceiling amount (Example:8.10-acre application fee is$000).
Checks should be addressed to NCDEQ.
7, Has an erosion and sediment control plan been filed? Yes ❑ Enclosed 1 ' No
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name_n_btZ Moore.. E-mail Address y 0o(e 'D bt'U ,m_ou.x.-60.-;n i rtc,
Phone: Office# 72..8 -1 8 -5a-11 Mobile#_12_8'- (- z�--1-2- 0`• (...6
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Phone: Office# Mobile#
Current Mailing Address I Current Strr et Address
City State Zip City State Zip
10. Deed Book No. a Q _`Page No. \ L 7'Ili Provide a copy of the most current deed.

Part B.
1, Company(les)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 sole proprietorship or If the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Com
panyNa'me •f^y/,\p-�[q 4y��T+ (r E-mail Address
�' V 1/ •tv
A !
Current Mailing Address Current Streettdr� s
2244
City State Zip City State Zip
Phone; Office# ® 1) _ Mobile tt 6 " 8 2.c3 T.5S-,3
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, Include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and 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:
Nam of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City - State Zip City State Zip
Phone; Office tt Mobile#
NamA
e of individual to Contact(if Registered Agent is a company)
(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:
N
Nam of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Nellie of Individual to Contact(if 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 registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Com any OBA Name
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(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.
Type or print name Title or Authority
Si ature Date
a - \TT S , a Notary Public of the County of VDU,V- 7 'J
State of North Carolina, hereby certify thatf rc', 'm-\-e> Qrs appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
VM
Witness my hand and notarial seal, this (..it a day of 20 /i5
�`��1�'4�� 4dt
+,�� ,Si,,� .,q;,,,t t. Notary
st
� My commission expire
aO 30
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