NCC220001_FRO Submitted_20220131

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
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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. Hinshaw Fox Trot
1. Project Name
2. Location of land -disturbing activity: County
Davie city or Township Advance
Highway/Street
Fox Trot Ln Latitude 35.94056 N Longitude80'43032 W
3. Approximate date land -disturbing activity will commence:
12/20/2021
Residental
4. Purpose of development (residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):1.0
6. 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? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tyler Hinshaw E-mail Address [e-mail]
Telephone Cell # (336) 254 - 6529 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Tyler and Mary Kate Hinshaw
(336) 254 - 6529
Name
Telephone Fax Number
356 Kingsmill Drive
356 Kingsmill Drive
Current Mailing Address
Current Street Address
Advance NC 27006
Advance NC 27006
city State Zip
City State Zip
10. Deed Book No.01170 Page No.0268 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.
Tyler and Mary Kate Hinshaw
[e-mail]
Name
E-mail Address
356 Kingsmill Drive
356 Kingsmill Drive
Current Mailing Address
Current Street Address
Advance NC 27006
Advance NC 27006
City State Zip
city State Zip
336-2546529
Telephone
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
Telephone
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
E-mail Address
Current Maifing Address Current Street Address
City
State Zip
City State Zip
Telephone Fax Number
I he 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.
Tyler and Mary Kate Hinshaw Owners
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Title or Authority
_ . 03 /0oat
Date
l,J W r4_ u B r i.'3n , a Notary Public of the County of _rQrs
State of North Carolina, hereby certify that h appeared
personally before me this day and being d ly sworn acknowlefted that the above form was
executed by him.
Witness my hand and notarial seal, this gyof
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