NCC243462_FRO Submitted_20241107

I
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
I No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this
s fomi and an acceptable erosion and sedimentation control plan have boon 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.)
i t
Part A.1. Project NameCarolina Crossing Lot 23 I
Chatham Apex t
2. Location of land-disturbing activity: County City or Township
Highway/Street 110 Cadens Way Latitude 35°47'48.6"N Longitude 78°57'36.5"W
3. Approximate date land-disturbing activity will commence:
11/8/2024
I4. Purpose of development(residential, commercial, Industrial, Institutional, etc.):Residential
! 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):0.98
6. Amount of fee enclosed: $ 120 . The application fee of$100.00 per acre
(rounded up to the next acre)Is assessed without a ceiling amount(Example: 8.10 ac=$900.00). '
1 7. Has an erosion and sediment control plan been filed? Yes X No Enclosed X
i 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name Robert Sluik E-mail Address [e-mail]
Telephone [phone] cell# Fax#
!
t 9. Landowner(s)of Record (attach accompanied page to list additional owners): •Sunil Kalidindi
i Name Telephone Fax Number
i
I 616 Rolling Springs Dr
1 Current Mailing Address Current Street Address
i Cary NC 27519
ICity State Zip City State Zip
10. Deed Book No.2185 Page No.0472 Provide a copy of the most current deed.
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Part B. t
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
i comprehensive list of all responsible parties on an attached sheet.)If the company or firm is a sole proprietorship, i
ithe name of the owner or manager may be listed as the financially responsible party. i
I Robert Sluik [e-mail]
1 Name E-mail Address
8241 Raleigh Rd
Current Mailing Address Current Street Address 1
Benson NC 27504
City State Zip City State Zip t
[phone]
Telephone Fax Number

2. ,a' :~e a . ; \. Sies ' s S'e Fa;), is rot a res dent cf North Ca ro ra, g...e name and street add'ess
:`.`e ce__::te:: \a t.h Car ,a:e t.-
Robert Sluik [e-mail]
Na.-e E-ma'l Address
109 Professional Ct unit 105 109 Professional Ct Unit 105
ln:: t!, aT.- A....-ess Current Street Address
Gamer NC 27529 Gamer NC 27529
C.1• State Zp City State Zip
i e'epha:e Fax Number
(5) If:he rL anaia.:'• Responsible Party is a Partnership or other person engaging in business under an
assjmad came, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party s a Corporation,give name and street address of the Registered Agent:
Na Me.of Registered Agent E-mail Address
Current?. aTngAddress Current Street Address
Cy State Zp City State Zp
T e+e pone 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 artomey-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.
Robert Sluik Managing Member
Type or prin m Title or Authority
11/6/2024
Signature
.( Date
I, 11)r' ri alh� t3 , a Notary Public of the County of SOhY15\t L'
State of North Carolina, hereby certify that Y It`t t4 ll appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him. �1U�l�, ,
Witness my hand and notarial seal, this lsr day of 1J .h1kr , 20 n�l4
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