NCC222744_FRO Submitted_20220802

W Erosion and Sedinwatation Cootrof
Financial Responsibility/Owoetship Form
'LEASE MAI`€ _ LQLWWM INEO *+�'%)
1)'Mis sectiou milt be s1ped it) OW Pme"M ofa NAMY
,I) All )And-Pisnwbingg pawits We valid lot up to t-} years from dic doc of ismwc . if circarnswest, ft permil may
for (ZI yrars per ft cooditiom of the f ii Erosion amd dirtrei'itatwn cotaml or&fflanccUpon wrbm
nand ., the Land-INsturbing ponots ;ray be ftV0kxd for fail to comply with tbc Ordirtancat-if the permit hr revoked, all odw
permhs and z6 am wilt eld tail the property kcmcc apin in OomOjWxV with CUjham County re plations, A60, UPOO
written noticc, a civil pertalty (fine) care be bWgaWd against the rty o*jw ate{ tad` '"W firsancially responsible, }amity Cif )
for viol " s of dwebathm CMny soil &OSM and riaiemtat COWVW ord"cn ce 'MIS penalty is up to . ,OU l Violat`
pet' day and is awdaily Me evay day the property is in violation. lateifeting.with or haeopering an irnpectim can, mult is a civil
patalty w i
3) the infornattioo ps rill on this fc c i ts Wx and mr4vt to the bm of my knowkdgc arw Wiefund was pwvi&d bypie while
ander cam
4) This tom i us-t be -�igprd tsy the, property owner if an individual, if owned a cmnpany or corporatim the form must be 6grictl
by an off , directer, ,fi r,; paWn wadi audwrity to ex eats for the corporMon and
t aip -Vicd tsy .a *Mpk4e list ofall a 'rag roembers mW reftwred ajents the company
if apple r::)m
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Name and Title.
NOWIM CAROLINA AGENT (if any):
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Company
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appmW bclkrcand d:. - zidk�lcdpd rwding
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above li�vm was f by Mm or her.
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