NCC240872_FRO Submitted_20240326

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 Environment and Natural Resources. (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 FRY STREET BORROW PIT
2. Location of land-disturbing activity: County LEE City or Township EAST SANFORD TOWNSHIP
Highway/Street FRY STREET/CONE STREET Latitude 35 DEG 28' 55" Longitude 79 DEG 09' 05"
3. Approximate date land-disturbing activity will commence: IN PROGRESS
4. Purpose of development (residential, commercial, industrial, institutional, etc.):BORROW SITE
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):2.2 AC
6. Amount of fee enclosed: $300. The application fee of$100.00 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 Mr. Brandon Harrington E-mail Address brandon(a.harringtonpropertiesofnc.com
Telephone N/A Cell #919-770-5969 Fax# N/A
9. Landowner(s)of Record (attach accompanied page to list additional owners): SEE ATTACHMENT
TRIPLE H FARMS OF LEE COUNTY, INC. 919-770-5969 N/A
Name Telephone Fax Number
2659 SAN LEE DRIVE SAME
Current Mailing Address Current Street Address
SANFORD NC 27330
City State Zip City State Zip
10. Deed Book No. 01480 Page No. 473-476 Provide a copy of the most current deed.
Part B.
1. Person(s) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
TRIPLE H FARMS OF LEE COUNTY, INC brandon(a�harringtonpropertiesofnc.com
Name E-mail Address
2659 SAN LEE DRIVE SAME
Current Mailing Address Current Street Address
SANFORD NC 27330
City State Zip City State Zip
Telephone [phone] 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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach 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:
Name of Registered Agent E-mail Address
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.
BRANDON HARRINGTON VICE PRESIDENT
Type print name Title or Authority
J)-/!/29 2 /
Signature Date
14 1 L t ((y Li Q 6 Y I a NotaryPublic of the Countyof Lee
State of North Carolina, hereby certify that hra II aO1I ( ri tij W" 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 1 `'t' day of 1-Y(6
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Diary
Seal `" - r ( f�
�'s�`G �;'� �r c'u My commission expires
.... •
:

FRY STREET BORROW PIT
ATTACHMENT TO THE FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
PART A.9
Additional Land Owners of Record:
HARRINGTON PROPERTIES OF NC, LLC [e-mail]
Name E-mail Address
2659 SAN LEE DRIVE SAME
Current Mailing Address Current Street Address
SANFORD NC 27330
City State Zip City State Zip
Telephone [phone] Fax Number N/A
PART A.10
Deed Book No. 01557 Page No. 472-474 Provide a copy of the most current deed.