NCC222772_FRO Submitted_20220803

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 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_ 3 r LI 24 k Live L ✓ten
2. Location of land-disturbing activity: County t4.r kr City or Township Mar j .n Ian
Highway/Street 134c e 1,.. Latitude 3 S. 715, 10 Longitude - 5-l. ‘,C54 51 O
3. Approximate date land-disturbing activity will commence: (/ IC /94c)Q-2
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Pe c:jet. i•ict.
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): C5.r)5 4crr
6. Amount of fee enclosed: $ 100 . 06 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name errn I<< born E-mail Address bSrc,bor est.) . col,
Telephone '%04 - Li ar- j 94 a- Cell # t)O - I r)4 Fax # N/
9. Landowner(s) of Record (attach accompanied page to list additional owners):
bfy 6n ILLnCR 96 '-t - Lt“" - 19 f NlR
Narrfe Telephone Fax Number
1 I I & IgIel,rle„ O, I tI 41Jer le‘, ar
Current Mailing Address Current Street Address
rt.. u.G VQr e, A/C / 5 C Fi...taay :R4 Of?
Crti State Zip City State Zip
10. Deed Book No. Page No. 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.
3c1c, Qchocti _ b.6 calarn nGSU.
Name E-mail Address
_ ) 1t I,S Or. 1I1 UirJe4 Or,
Current Mailing Address Current Street Address
cetidevVar 5 Vdr A/C 0-95 ro
rl�(a r
City State Zip City State Zip

1
Telephone De, - 4*6.- I 4¢ 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:
N /A
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
r�1 A
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
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.
Br y C. 11 �b0 � � �,CN 1-
/ tip L.: ` ige 5 DA s. J(c Pes San /LoC� w O n e
Type or print name Title or Authority P
Signature Date
)14,e6,..- NT y , a NotaryPublic of the Countyt
of lt„J�� te_
State of North Carolina, hereby certify that S 1 -0 S4 /4 tit I / 1 t c fn
appeared
personally before me this day and being duly swoni acknowledged that the above form was executed
by him.
Witness my h uilianc4,notarial seal, thi•s 2 day ofS ��J' 20
D R•
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* * * . _ Notary
Seal
;� •. • • • My commission expires vim— 23'`'• ?o
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