NCC220141_FRO Submitted_20220107

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. 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. Kummerer
1. Project Name
2
3
4
5
6
Location of land -disturbing activity: County Union
Highway/StreetWeddington Mathes Latitude35.054
City or TownshipWeddington
Longitude 80.7290
Approximate date land -disturbing activity will commence:01-01-22
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas):'80
Amount of fee enclosed: $ 100.00 . 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).
7. Has an erosion and sediment control plan been filed? Yesx No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Troy Ludemann E-mail [e-mail]
Telephone[phone] Cell # 704-975-3770 Fax # NA
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Robert Kummerer
803-370-3149 NA
Name
Telephone Fax Number
7523 Meadowgate Ln
7523 Meadowgate Ln
Current Mailing Address
Current Street Address
Waxhaw NC 28173
Waxhaw NC 28173
City State
Zip City State
Zip
10. Deed Book No.7847
Page No.0196 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.
New Old, LLC
[e-mail]
Name
E-mail Address
2269 New Gray Rock Rd
2269 New Gray Rock Rd
Current Mailing Address
Current Street Address
Fort Mill SC 29708
Fort Mill SC 29708
City State
Zip City State
Zip
Telephone[phone]
Fax NumberNA

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:
Robert Kummerer
[e-mail]
Name
E-mail Address
7523 Meadowgate Ln
7523 Meadowgate Ln
Current Mailing Address
Current Street Address
Waxhaw NC 28173
Waxhaw NC 28173
City State Zip
City State Zip
Telephone[phone]
Fax Number NA
(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.
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Title or Authority
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Date
I, , a Notary Public of the County of JNI1
State of R�Carolina, hereby certify that (, appeared
personally before me this day and being duly swrish acknowledgecr that the above form was
executed by him.
Witness my hand and notarial seal, this _L�day of bP�eIM ,V , 20
a.aelaGr' SC
.1 Notary
i 1 ; so or s My commission expires
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