NCC221374_FRO Submitted_20220407

FINANCIAL RESPONSIBILITYIOWNERSHIP 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
pro riate
Regional Office. (Please type or print and, if the question is not applicable or the e-mail addressor phone
number is unavailable, place N/A in the blank.)
Part A.
1, Project Name —House construction
2. Location of land -disturbing activity: County_Burke City or Township —Morganton
Highway/Street 3240 hock Creek Rd_ Latitude(decimai degrees) 35.703 Longitudeidecimai degrees-31.615
3. Approximate date land -disturbing activity will commence:_30 March 2022
4. Purpose of development (residential, Commercial, industrial, institutional, etc.):�Residential
5. Total acreage disturbed or uncovered (including Off -site borrow and waste areas):®0.95 acre_
6. Amount of fee enclosed: 100,00 The application fee of $100.
up to the next acre) is assessed without a Ceili00 per acre (rounded
Checks should be addressed to NCI�EQ. ng amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes Cl Enclosed %< No ❑
3. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Robert Strini E-mail Address bob.strini@ebs-Inc oro
Phone: Office # H: 386-6_ 24-= Mobile # 336-7___q_.g_7321
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Robert and Laurie Strini 386-624-6537
Name Phone: Home # 386-7-- 41
Mobile #
1035 Old Pond Rd
Current Mailing Address
Deland FL 32724
City State Zip
10. Deed Book No._002557 Page No._...00022
Provide a copy of the most Current deed.

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
A to Z Operations U. jtanthonYO-me com
Company Name E-mail Address
3943 Zero Mull RD 3943 Zero Mull Rd
Current Mailing Address Current Street Address
Morganton NC 28655 Morganton NC 28655
City State Zip City State
Zip
Phone: Office # 828-443-7577 Mobile # [phone]
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
John Anthony
Name of Registered Agent
3943 Zero Mull RD
Current Mailing Address
Morganton
City
jtanthony .me.com
t-mail Address
3943 Zero Mull Rd
Current Street Address
NC 28655 Morganton NC
State Zip City State
Phone: Office # 828-443-7577 Mobile # [phone]
John Ant ony
Name of Individual to Contact (if Registered Agent is a company)
28655
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
John Anthon 6 Member
Type r, Title or Authority
`ignature Date
111'� V,30

Property Owner Authorization Letter 30 March, 2022
I, Robert A. Strini, Landowner of 3240 Rock Creek Rd, Morganton NC 28655, authorize
A to Z Operations, LLC, 3943 Zero Mull Rd, Morganton, NC, 28655 a Grading and Excavation
company to perform operations to include land disturbing, clearing, septic, erosion control and file my
Soil and Erosion Control Plan with NC DEQ. Questions concerning the clearing and excavation of
3240 Rock Creek Rd should be directed to Mr. John Anthony as stated in Part B.
;i
Robert A. Strini Date: d,3 0 /;10
Signature:

a Notary Public of the County of
State of North Carolina, hereby certify tha 1 A 6h A IN' abefore me this day and being duly sworn acknowledged that t e above forwas appeared personally
(' ex�yecuted by him/her.
Witness my hand and notarial seal, this %A day of I 20 I f
a�'22G�P G - MC
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My commission expires
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