NCC223762_FRO Submitted_20221103

Durham City/County
Sedimentation and Erosion Control
JCN
(Office Use Only)
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
im)
M
WITH LANDOWNER CONSENT FORM
No person may initiate any land -disturbing activity covered by the Durham City -County Unified Development Ordinance before a
Land Disturbing Permit is issued by the Sedimentation and Erosion Control Office. Issuance of a Land Disturbing Permit does not
relieve the permittee of the obligation to obtain any other licenses, permits and approvals as may be required by Federal, State,
County or Municipal governments. This office must be notified in writing of any change to the information on this form.
PLEASE TYPE OR PRINT
Project name: ACR Supply Expansion Entitlements
1. Road location of land -disturbing activity:_along _S. ALSTON AVE
Tax Map - Block - Parcel: _157211
PIN: 0738-01-29-7465
3. Square footage of land to be disturbed or uncovered:_122,050sf (2.8 acres
4. List below the landowner of record. Each landowner must complete Item S.
(If there are multiple owners, please list on a separate page):
_ TMLO Investments, LLC
Name
_4040 S Alston Ave
Address
Durham
City
_919-313-4344
Telephone
NC
State
Fax
27713
Zip
Email
5. List the person or entity financially responsible for this land -disturbing activity: The financially responsible party shall
be (1) the developer or other person who has or holds themselves as having financial or operational control over the land -
disturbing activity and/or (2) the land owner or person in possession or control of the land when they have directly or
indirectly allowed the land -disturbing activity or have benefited from it and (3) the named party on the Land Disturbing
Permit.
_ TMLO Investments, LLC
Name
_4040 S Alston Ave.
Street Address
_ Durham
City
_919-313-4344
Telephone
NC
State
Fax
27713
Zip
Email
The Sedimentation and Pollution Control Act (Act) and the Durham City -County Unified Development Ordinance
(Ordinance) includes, but is not limited to, the following legal obligations of the financially responsible party:
■ Maintain a set of approved sedimentation and erosion control plans, if required, on site.
■ Display permit on site.
■ Understand and implement any required plan, including the construction sequence and details.
* Inspect, maintain and repair sedimentation and erosion control measures, especially after rainfall events.
■ Provided adequate ground cover or otherwise stabilize all areas that have not been actively graded within 21 calendar
days.
■ Plan and conduct all land -disturbing activity so as to prevent off -site sedimentation.
201 E. Main St, 51h Floor, Durham, N.C. 27701 ■ [phone] ■ Fax [phone]
www.co.durham.nc.us/ceng

6. For business applicants, list below the North Carolina registered agent for the financially responsible entity:
_Troy L Meachum
Name
_4040 S Alston Ave
Street Address
_Durham
City
_919-313-4344
Telephone
NC
State
Fax
27713
Zip
Email
7. The above information is true and correct to the best of my knowledge and belief and was provided by me while under oath. I
understand that the person or entity listed on Line 5 above will be: (1) the owner of the Land Disturbing Permit when issued;
(2) responsible for ensuring compliance with the Act and Ordinance; and, (3) will be the only person or entity with standing to
appeal any action taken or decision made by the Sedimentation and Erosion Control Office.
OC-11) 0 « ZN �7 0 2-2 Troy L Meachum
Date Type or Print Name
�l _21 H3 `{�I 1°l zs� -ilb% Manager
Telephone Fax Title or or-
-'i-r' e, A CQ, S' L4 Ly , Co (-
Email - Si
Business Applicant (Provide coM rate resolution on signatory authority) I.
_,a Notary Public of the County of I
State of 1 or" h &Q Y� I , hereby certify that L • IT" k L' �� � ►ff�_
Ab
personally came before me this day and acknowledged that he is C�
ofrh LO and acknowledged, on behalf of } 1 41- t3 �
a �=
the due execution of the foregoing instrument. �Q��
Witness my hand and official seal, this day ofl�� 20
Notary Public
My commission expires_J o / c 20
Individual Applicant
I,
State
a Notary Public of the County of
hereby certify that
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this day of
My commission expires
20
Notary Public
LAND DISTURBING PERMITS ARE NON -TRANSFERABLE
20

Provide a Notarized Item 8 for each landowner listed in Item 4.
8. Land Owner Consent. As a landowner, I provide my consent for land -disturbing activities to occur on the property listed in
Item 2 by the person or entity listed in Item 5.
Date
Telephone
Fax
Type or Print Name
Title or Authority
Email Signature
Business Landowner [Provide corporate resolution on signatory authori
I, a Notary Public of the County of
State of , hereby certify that
personally came before me this day and acknowledged that he is
of and acknowledged, on behalf of
the due execution of the foregoing instrument.
Witness my hand and official seal, this day of
My commission expires 120
Individual Landowner
I,
State
Notary Public
a Notary Public of the County of
hereby certify that
20
personally appeared before me this date and under oath acknowledged that the above form was executed by them.
Witness my hand and official seal, this day of_ , 20
My commission expires
20
Notary Public
5E-03 Rev.07/06