NCC220717_FRO Submitted_20220210

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 NIA in the blank.)
Part A. Cotton Farms Phase 1
1. Project Name
2. Location of land -disturbing activity: County Harnett City or Township Hectors Creek
Highway/Street 25 Deer Tail Lane Latitude 35d3O'O4" Longitude-78d51'32"
1 Approximate date land -disturbing activity will commence: 11 11 i✓2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):•
$1040 PrPvirnis na; me.nt 914
6. Amount of fee enclosed: $ . 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 X No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Clint Reese, Jr E-mail Address reeseconstruction@hotmaiLcom
Telephone Cell # 919-427-4685 Fax ft
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Reese Construction LLC 919-427-4685
Name
Telephone Fax Number
3720 Lucky Drive
3720 Lucky Drive
Current Mailing Address
Current Street Address
Apex NC
27539 Apex NC 27539
City State
Zip City State Zip
10, Deed Book No. 3912
Page No. 0977 Provide a copy of the most current deed.
Part B. 3913
0911
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.
Reese Construction LLC reeseconstruction@hotmaiLcom
Name
E-mail Address
3720 Lucky Drive
Current Mailing Address
Current Street Address
Apex NC 27539
City State
Zip City State Zip
Telephone [phone]
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:
Clint Reese, Jr
Name
Current Mailing Address
City
Telephone.
State
919-427-4685
Zip
[e-mail]
E-mail Address
3720 Lucky Drive
Current Street Address
Apex NC 27539
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 Zip
Telephone
E-mail Address
Current Street Address
City
Fax Number
State Zip
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. o
Clint Reese, Jr 6wftef Mere
Typ or print name Title or Authority
�J S ao�-�
Signature Date
I, jo ime_;,(),_,9 s , a Notary Public Of the County of
State of North Carolina, hereby certify that .S¢_ Y . 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 O%'_ day of , 20-),7
Jaime Zarnosky �s
Ngtgry Public Notary
Wake County, NC My commission expire5__] ��b dl