NCC221514_FRO Submitted_20220419

FINANC-CAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may in€t€ate Orly 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 EnAronrnental Quality. Submit the .completed farm to the.
appropriate Regional Office. {Please type or print and, If the question is not applicable or the a -mail andf
or fax information unavailable, place NIA In the bunk.)
Part A.
I. Project Name Y)� - ail f 1 1�►rl�Lr]
2. Location of land -disturbing activity: County C€ty or, Towship AS 6V0
Highway/StreetDlIdiil , hL4d Latitude d4l t/J 'I r�.1��11! Longitude Wo q7 f . JV-"Id
3, Approxirrrate date land -disturbing activity will commence; C . ]
4. Purpose of developMppi (residential, cornniercial, industrial, institutional, etc,):
51. Total aareage.disturbed or uncovered (Including off -site borrow and waste areas); e _ 5
6.. Amount of fee enclosed: $ The. applica#ion fee of $65.90 per: acre (rounded
up to the next acre) is assessed without a nailing amount (Example: a 9-acre appllcatfoiyfee is ;$,585).
7. Has an erosion and sediment control plan been filed? Yes .. No Enclosed. X
8. Person to Whiact should erosion and: sediment control issues arise during:larid-4sturbing activity:
Narme*09 Ho.f M .._ Email Address j)64A a) . , ,
Tel aphone ')) -'/04--1GEZ, hell # ' 10 ' - Fax:#
9. Landowner{s) of Record (attach accompanied page to list additional owners),
She b(Lo �L /7 �LLi✓�
Name Telephone Fax'Numtei
io (�Olrf arJ
Current Mailing Address
� ¢� A Al ..
Current Street Address
city
State
Zlp:
10. Deed Book_fUa �L —]Page No.1295 a791 Provide a copy of the mast:currant'deed,
Part a.
1. Corripany(les) 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 Me company orri'mAls a sole prnPrletvrslrlp;
the name ofthe-owner or manager may be listed 69 the financially responsfble.party,
I ` U
Current Mailing Address
City ffjj State Zip
Tele ph a ne "r-8, 3,13
Current Street Address
city State Zip
Fax Number

2. (a) If the Financially Responsible Parry is not a resident of North Carolina, give name and street addres8
ofthe desfgnated'North Carolina Agent:
Name
:Current Mailing Address
Email Address
Current Street Address
city state Zip City state Zip
Telephone Fax Number
(b) If the Financially Responsible Party Is a Partnership or athpr 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 nameand street address of the Registered Agent;
•L
Name of Registered Agent
E~-mall Add'rekW
Current Mailing Address Current Street Address
City VState Zip
City
Telephone Z 9 - (5D - ` 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 fora must be signed by the Financially Responsible Person it' an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the a4thorKy to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the Information provided herein.
TI: C It L' t2' Aa" 1', - z �, 'L- a �4 V 1,
T. J r rint name: �� Tlile ar tho 'ty `
G(-�AO
Signature pate
, a ,Notary public of the County of Gi L"o—
State of North Carolina, hereby certify thatGll(1_(� _ W Q l appeared
personally before me this day and being; duly sworn acknowledged that the above form was
executed by him. yya�►r►►
Witness my hand and notarial s@�I� S ' ' 9 20 CA
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Seal f�.f 25 •tyG�. [(� r
OUNT`t ��r�klvly commission expires 1-{ 2o? J
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