NCC240122_FRO Submitted_20240202

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 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_Rt$Szri/C jpnyoirT�- y U1f�J2SLt,oi�s
2. Location of land-distu:binti activity: Countylq21a)4cull6Ver City or Township WI IYy)in9-1-0y1
Highway/Street Tidy\ \- Latitude 34. 21.05 a3 Longitude -17. '935037
3. Approximate date lard-disturbing activity will commence: I 1 Iq 12DZ4
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Resick n-6&t
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 0,62
6. Amount of fee enclosed: $ NIA . 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 x No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name RG4XI -5atle9 E-mail Address \JJ 1 c:on @ �lbwee-bui ld�rs.cowl
Telephone C1 10- 541- �t3 LOZ Cell# 141 A Fax# N I
9. Landowner(s)of Record (attach accompanied page to list additional owners):
SeveMtj V\I2& B'tk eX5) Inc . (110-324- 444` 1 N/Kt
Name Telephone Fax Number
?O Pax Ib1 I 14$89 l-kicgh�ttc�.� I'? ,Sully C
Current Mailing Address Current Street A ress
VVOSY, 1•Lc, ZX441) 1r4 n,e 1 2 Z4d-4
City State Zip City State Zip
10. Deed Book No. ()64- D Page No. l$54 Provide a copy of the most current deed.
1gco 17(4, 173z IO2 1693
Part B. 11$3 1741 11111 (0-15
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.
5eme,orkiWeek $u I lclex5, Inc, onelisso, o�r10 W e A-bU I t ckers . carve
Name E-mail Address
PG Box U1 0 1452 t N-ich. Nab 1 n , Soy C-
II
Current Mailing11 Address Current Street Address
1- 03/A ra __ d1I V� 22 '1 Ol e A1��C. 22 4 "�
City State Zip City State Zip

•
Telephone gib-324 4441 Fax Number N/A
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:
d� nn
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone_ Fax Number
(b) If tie Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name,attarii 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:
j\j
Name"of Registered Agent E-mail Address
9 9
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.
eiCli. ' v 4-t,-) PreG i clQ,n+
Type or t name Title or Authority
I Ill I202-4
Signatur Date
I, QA,\SS(k_L 1€X15 , a Notary Public of the County of3(-Infito1l
State of North Carolina, hereby certify that C:xreu. sty\t i"t , appeared
personally before me this day and being duly sworn ackniowledged that the above form was executed
by him.
Witness my hand and notarial seal, this [lam day of 401'100X11 , 20 94
\\\��esSAi JNON�1,
ele4/16eV)
Notary Public -'fliQ��t/a4
Johnston Notary
S�unty
My Comm. Exp. My commission expires i i ( -OG-S
/, 02-01-2025 v-
/ //T11 CA 'VO\\\\\��