NCC221792_FRO Submitted_20220510

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 Environment and Natural Resources. (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. �/� �j
1. Project Name 1" �) O r' "` r, J. its rr�hS/d 11
2. Location of land -disturbing activity: County wq Ke City or Township Xa lei
'+301 L'ko0fr ►Nlq ?jr 6 �4q3
Highway/Street AoQ Latitude .5. 63 96 Longitude 1
3. Approximate date land -disturbing activity will commence: 6 f / T «oa 1
4. Purpose of development (residential, commercial, industrial, institutional, etc.): CommeJC/a
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 9.50
Amount of fee enclosed: $ A4 . 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 V No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name 3 A s V h G r e e k E-mail Address ' 9r� eeb ras�r'e/�QOI!"/L°. CO►'�'1
p� �
Telephone 1 I [ — d 9 '� oS g� Cell # 1a 11p —) 91 — Q of Fax # IVA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Nord J-}d is l e i% '/noes A (:uor tp 1/9- ? 1 ?- P /V�4
Name I Telephone Fax Number
q-3olI t4nifer of Nor% bills Ave• Sarigs 1Mzvl.,1/'OT
Current Mailing AddressA Current Street Address 10,
94/cia4 /VL ) l60q
City V State Zip City State Zip
0a7or2 - 001?16
10. Deed Book No. 016 16 8 6 Page No. Provide a copy of the most current deed.
Part B.
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):
No ro, P)115 Rekl rXP+nsia% L)WHer, LP SKane rea Mr/.C_0M
Name E-mail Address
q-3dl (A. Si /Yr Af 15 A'Ue . �4* e is
Current Mailing Address Current Street Address
Weil , JAG C)uo9
City T State Zip
City State Zip
Telephone q19- 1 r —S` !D Fax Number PA

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
A
NA
Current Mailing Address
N A -
City State Zip
Telephone N
NA
E-mail Address
NA
Current Street Address
/y
City State Zip
Fax Number N A
(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:
AA Wis 9e0ail owht LP sl�� I1 C kg►,e cY�l-�y �orO.ccvh
Name of Registered Agent E-mail Address
q 3 � 1 4ffIj , of Vgg Qt3 Ave. SMVKC as 1s1ai1ika
Current Mailing Address Current Street Address
Ar/e,44 NC a 7601
City State Zip
Telephone 9 /9 - / �% - 51 /r� g
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.
5,e0.h Ili I I
Type or print name
Signature
-------------
Title or Authority
Date
5- If - ao as
I, t�L j 1 S. 2>U_%^k-On , a Notary Public of the County of _ W Q ul
State of North Carolina, hereby certify that ReAn �t\�� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my ftaO14kndOW;* l seal, this �m day of � , 20 _
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Is-
G otary
S,Z'paAUB0 •'2V
�''•-1, •' °y, My commission expires 7 Gi / Z429