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HomeMy WebLinkAboutNCC216669_FRO Submitted_20211201FINANCIAL 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 �V N I5 Kt7 fi"'VtrN pogo- I 2. Location of land -disturbing activity: County IVA"W IJA'Alav City or Township Lea �AA1'£O Highway/Street Y,0 0 64"11�* P 9 Latitude '31. 1 S 9y Longitude 3. Approximate date land -disturbing activity will commence:_ ��✓ �fQ� S42, 1 4. Purpose of development (residential, commercial, industrial, institutional, etc.):Sl P�"J 1141_ 5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5g , 5 6. Amount of fee enclosed: $ 319 5). 2 !� . 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 No Enclosed .. 8. Person to contact should erosion and sediment control issues arise during land -disturbing activity: Name fi// KJ ��-S E-mail Address /t �1� ec- wfon 6: • C0 y1" Telephone 1 i� " IGLU "U Cell # q1 +1-9I1,- ": Fax # g1 r1 744-- MtrO 9. Landowner(s) of Record (attach accompanied page to list additional owners): &P1 Po r-0 p 4 tirwtA3 it, 90 ab2-- &60 Name Telephone Fax Number 12v t G*f'q r4roa S'A 0i� Current Mailing Address Current Street Address H/w rn,1yv`TeN NC.' z4y 1 0 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. Name E-mail Address 1201 Eric& A49A Ot A oA Current Mailing Address Current Street Address City State Zip City State Zip Telephone 'It e U-4-6 � Fax NumberlJ r 4& y— W);O 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: ivame Current Mailing Address t;ity Telephone E-mail Address Current Street Address State Zip City State Zip 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 Current Mailing Address City State E-mail Address Current Street Address 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. PV�J i* rr' ' 444&Alr 11 Type or print me Title or Authority Signature Date a Notary Public of the County of State of North Carolina, hereby certify that A i E?�S appeared personally before me this day and being duly sworn acknowledged th t he above form was executed by him. -�rWitness my hand and notarial seal, this My commission expires J — � . >