NCC223690_FRO Submitted_20221028

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 Warrenton Dollar
3.
4.
7
M
10
Location of land -disturbing activity: County_Warren City or Township_Warrenton
Highway/Street Tower Rd Latitude 36.344376 Longitude-78.216207
Approximate date land -disturbing activity will commence: Nov 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
Total acreage disturbed or uncovered (including off -site borrow and waste areas):_2.02
Amount of fee enclosed: $ 300 . 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).
Has an erosion and sediment control plan been filed? Yes No_X Enclosed
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Matt Williams E-mail Address mattrhetson.com
Telephone [phone] Cell # 910-690-0155 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
Rhetson Companies. Inc
Name
2075 Juniper Lake Rd
Current Mailing Address
West End NC 27376
City State Zip
Deed Book No. 164 Page No.`
Part B.
910-944-0881
Telephone Fax Number
Current Street Address
City State Zip
223 Provide a copy of the most current deed.
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.
Name-�S C��9a�,.`fS , a ;t, ca
E-mail Address
207� Jv^i' #r Ut f l !f^ME
Current Mailing Address Current Street Address
W 0C 77374 5AMr
City State Zip City State Zip

Telephone_ (q10) Sq q' 011 _ 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
Telephone
E-mail Address
Current Street Address
State Zip City
Fax Number
State Zip
(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 State Zip
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.
3ayynxe, S . E.rx_� rNma, Ey 1? b_� c��li 17Y1
Type or print names Title or Authority
Sign r
Date
I, i V sa r.rn-c znc _ a Notary Public of the County of Moor; i
State of North Carolina, hereby certify that jarA,`r_ S . ,c�c�nasZs _ appeared
personally before me this day and being duly sworn acknowledged that the above form was executed
by hio. SIC
Witness464 ial seal, this
OTA
a SeaY�IG -
ZZ day of A j..yr , 20 2-Z
Notary
My commission expires 62Z5 k6z_Y