NCC221331_FRO Submitted_20220407

NC Department of
Environmental Quality
Received
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT APR Q 2022
EXPRESS PERMITTING OPTION 11192021 Winston Stem
No person may initiate any land -disturbing activity on one or more acres as covered by thR4�VbWO ice
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.
1. Project Name Isometrics, Inc.
2. Location of land -disturbing activity: County Rockingham City or Township Wentworth
Highway/Street NC Hwy 87 Latitude 36.368833 Longitude -79.720583
3. Approximate date land -disturbing activity will commence: 04/15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3.0 AC.
6. Amount of fee enclosed: $ 1 ,050.00 The Express Permitting application fee is a dual charge.
The normal fee of $100.00 per acre is assessed without a ceiling amount. In addition, the
Express Permitting supplement is $250.00 per acre up to eight acres, after which the Express
Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,900). NOTE: Both
fees are rounded up to the next whole acre and need to be paid by separate checks to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Ian Bracy E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Isometrics, Inc. [phone]
Name Telephone Fax Number
PO Box 1671 1266 North Scales Street
Current Mailing Address Current Street Address
Reidsville, NC 27323-1671 Reidsville, NC 27320
City State Zip City State Zip
10. Deed Book No. 1608 Page No. 2474 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.
Isometrics, Inc. [e-mail]
Name
PO Box 1671
Current Mailing Address
Reidsville, NC 27323-1671
City State Zip
E-mail Address
1266 North Scales Street
Current Street Address
Reidsville, NC 27320
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. -
Name
Current Mailing Address
City State
Telephon
E-mail Address
Current Street Address
Zip 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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Hugh Creed Associates, Inc., PA [e-mail]
Engineering Firm or other consultant
Dalton Ward
Individual contact person (type or print)
E-mail Address
[phone]
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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Type or print name
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Sign ture
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Title or Authority
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Date
, a Notary Public of the County of n
State of North Carolina, hereby certify that ��n�(i\5 i`�l • �rQG�-I appeared personally
before me this day and being duly sworn acknowledged that the above form was e ecuted by him.
Witness my hand and notarial seal, this 0Z� day of \_V'_lQrC_V) 20 ala
WENDY MARTIN Notary
Seal NOTARY PUBLIC
Rockingham County My commission expires ao0 �s
North Carolina
My Commission Expires May 31, 2025