NCC241467_FRO Submitted_20240514

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. (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 tic*JA VECC gar PO Ai Ici/ — pa.2.
2. Location of land-disturbing activity: County W4 hUrt,4 City or Township
Highway/Street ber/ 12D Latitude' 29 12 4 M Longitude or j _! 3S:ji
3. Approximate date land-disturbing activity will commence: A' o 2
4. Purpose of development(residential, commercial, industrial, institutional, etc.): gairFlIDAL-
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): /5:7S-
6. Amount of fee enclosed: $ 4}L�• °® . The application fee of$150.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is$1350).
7. Has an erosion and sediment control plan been filed? Yes / No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 7)EV2Ek SL alAA 4A/ E-mail Address 7) E/ t3 Al EZ4,066" tt
Telephone Cell# spa-s 07` 89/p Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
1(47"& MA/b /1 cvA/fg 44.4. `8o_'f4'4- c
Name Telephone Fax Number
Current Mailing Address Current Street Address
ptia),E6Mar NC Zbl/7
City State Zip City State Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
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.
t/ /O- /A t1O > 'Y7y/1/ ea ,z,'r- e EUVI 7t--/AUpC ktjo 444'1
Name E-mail Address
/ W/LuAMON/ 1 SrE- 207
Current Mailing Address Current Street Address
AlopErt/f AK, 20117
City State Zip City State Zip
Telephone 733U'44fq- 2'1 Fax Number ///

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.
D?fi Wie L NAlatoere
Type or print name Title or Authority ri
Signature Date
g. GA/ ''1)�,00, , a NotaryPublic of the Countyof rJ
l� Aft/ �t r� �
State of Pd �r�a, hereby certify that i1 lai/ ' 10" We'(( 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 04, i day of YLI , 20 ot`t
4Nota
VOL 66(AU(41°7
Seal
My commission expires
Anne B.Gardner
Notary Public,Alabama State At Large
My Commission Expires 2-15-2026