NCC221228_FRO Submitted_20220401

FINANCIAL RESPONSIBILITYlOWNERS19W 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 Environment and Natural Resources. (Please type or print and, if
the question is riot applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
I . Project Warne Steve Hargis Commercial
2. Location of land -disturbing activity: County lohnston City or Township Smithfield
Ilwy 70 Bus 35033'50.47"N 78023'22.39"XV
Highway/StreetLatitude Longitude
3. Approximate date land -disturbing activity will commence: Upon Receipt of hermit
4. Purpose of development (residential, commercial; industrial, institutional, etc.):
Commercial
�. Total acreage disturbed or uncovered (including off site borrow and waste areas): 13
6. Amount of fee enclosed: $ 545.00 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 X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Steve Hargis E-mail Address rshas,[e-mail]
Telephone [phone] Cell # 919-631-3030 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Steve and Cathy Hargis 919-631-3030 NIA
Name Telephone Fax Number
1 199 Crantock- Road I ] 99 Crantock Road
Current Mailing Address Current Street Address
Smithfield NC 27577 Smithfield NC 27577
City State Zip City State Zip
10. Deed Book No. 0�433 Page No. 0855 Provide a copy of the most current deed.
part S.
1. Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
Steve. Hargis rshar�=is@autloof:.com
Name E-mail Address
1I99 Crantock Road 1199 Crantock Road
Current Mailing Address Current Street Address
Smithfield NIC 27577 Smithfield NC 27577
City State Zip City State Zip
Telephone 9I9-631-3030 Fax Number i�/A

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:
NDIA
Name
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
State Zip
(b) 11 the Financially Responsible Party is a Partnership or other person engaging in Business under an
assumed name, attach a copy of the Certificate of Assurned Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
NIA
Name of Registered Agent
Current Mailing Address
City
T
State
F--rna.if Address --
Current Street Address
Zip City State Zip
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). 1 agree to provide
corrected information should there he any change in the information provided herein.
Type or print name
A
�Signatuna
�1�J -
Titfe or Authority
Date
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1, ` a Notary Pubfic of the County of
State of North Carolina, hereby certify that-2 aPp eared
personally before me this day and being duly swum acknowl ged that the alcove fora} was
executed by him.
Witness my hand and notarial seal, this dl day of 2
MARY KAY NEWCpMB •C—
Nota P . Nota
I bIi�, North Carolina
my �' is �� Exp;res My commission expires