NCC240575_FRO Submitted_20240305

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Attach a copy ny the Lm8uroy/n&xttoFund
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL AK%l[
No person may initiate any land-disturbing activity on one or more acres as covered by the Act, including any
activity under e common plan of development of this size as covered by the NCGO1 permit' bo8nne this form
and on 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'mo1| address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name -^ Jewett Aa���� Subdivision
'11'this project in ericon Res (ARPA) ftmds. list the Pmjoot Plame or Project
Number(o.q., SHP-C>~4RF-0f21) below under which you were approved for funding through the
Division uy Water lohaxbootumU}NN.
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2. Location cf|ond'd{aturbing activity: Cnunty^ ' City orTnwnoh(p ^�
�� Jewett Avenue 359�l3 -782505
Highway/Gtre��^-` � `^ " " Lab�ud�m^o/wa/xeomo"� � Long|�udo(o°mma/oanmvm �
3. Approximate date land-disturbing activity will commence: 12/1/73
Residential
t' U
^ ^63�|w�� |��:
4. Purpose of development kms|denbm[ oommen�a[ indu�ha[ |noU��nnm|' eto.): `
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5. Totalacreage disturbed or uncovered (including off'nibm borrow and waste areas): " ^��= "
�
H. An�oundof fee endooed: $ �K�
"-== . The application fee nf&1UD.00 per acre (rounded
upho the next acre) io assessed without a ceiling amount (Example: 8.10-acre application fee is $900)-
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes El Enclosed 171 No El
R� Person tu contact should erosion and sediment control Issues arise during land-disturbing activity:
����,���� �^^������ aeu/ere180�a�oo�eenQiOeg[|ng0Or�
Nome ^-^'` ^ ^~~ ^~^^~^ E-mail Address ' '
���.������1 ��
Phone: Office# ��"- ��� � ' =� Mobile#
R. Landowner(s)of Record (attach accompanied page to list additional owners):
Rob00'F Inc 919.497-6906
Name Phone: Offioa# Mobile#
100 S Smithfield Road 100 S Smithfield Road
Current Mailing Address Current Street Address
City State Zip City State Zip
������ ������
10. Deed Book No."-"-=-` _PagmNo. = "=~~ -Provide e copy uf 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 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).
Robmir Inc [e-mail]
Company Name E-mail Address
100 S Smithfield Road 100 S Smithfield Road
Current Mailing Address Current Street Address
Knightdale NC 27545 Knightdale NC 27545
City State Zip City State Zip
Phone: Office
919-497-6906 mobile it [e-mail]
#
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name 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:
_
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name 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.
Company DBA 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.
Jackie Robertson Owner
Type or print name Title or Authority
cc� 123 �2�
Signa re Date
I, , a Notary Public of the County of L3 K Le,
State of North Carolina, hereby certify that Ci6D n appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
ocL
Witness my hand and notarial seal, this 10(J day of 120
OTARy';�, No ry
Seal _ N 1 J L3 Do`s
- � My commission expires
�FCOUN T`'.
�1IIII ,

Continued from Items 9 & 10 in Part of the Financialo I ist ll lando Responsibility/OwnershipForm for multiple
owners. Attach copies of this pageas
Landowner 2 of Record:
/rI/F///l /9r 9164o 6-48&
Name Phone: Office# Mobile#
/OUSSrl/ Pe/elld /00 c .5,--- ,',m(', c,1,t /2r)(
Current Mailing Address Current Street Address
c_ 27s4-c ieN i5.-1,09� �c 29S4.s
City State Zip City
�N'J�T�f�I� I� State Zip
Page Book No.
Pa a No. Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City
State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City
State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.