NCC230420_FRO Submitted_20230214

FINANCIAL RESP.ONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
9 . Project Name GUI-N�AWT 2MU46 5 n O"
2- Location of land -disturbing activity: County. F OCK-1 INGHAI► City or Township 1 UI= FN
4U�AKTSP�►hYf� �oa�r
Highway/Street 5. Fri • 2023 Latitude 3b• 4S3d° Longitude 7J- 59445
3. Approximate date land -disturbing activity will commence:
4. -purpose of development (residential, comrnercial, industrial, institutional, etc.): INST?ZU m10 L
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3. 0 Ae,-
5. Amount of fee enclosed: 00 Iao.,prD
up to the next acre) is assessed without a ceiling amount e(Exam�pl : a 9 a tion fee �e application tier fee s (rounded
SW
7. Has an erosion and sediment control plan been Bled? Yes
NoEnclosed X _
8. Person to contact should erosion and sediment control issues arise during land disturbing activity:
Name :1-KE L 0�5 iV(Cri i. E-mail Address dc1n�'idet"illldtCrltl6.� Be�i7 r�thai1.6ve+�
Telephone 33& - &Z'5 2 52(o Cell # 33&- 432 7722 Fax# 33la �Ga�3-i4�E�
9. Landowner(s) of Record (attach accompanied page to list additional owners):
tJI.As -A L - WOFiK W tTH t f rA. G. P.O.T E%
Name _ Telephone Fax Number
Current Mailing Address Current Street Address
City State Zip City State ,Zip
10. Deed Book No. Page No. Provide a copy of the most current deed.
Part B.
.I. 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):
PAN NVEP`r W 5F� 7" If4e,
Name E-mail Address
Ca 10 PATF71Gl`7 STF,E�'
Current Mailing Address 'Cu it Street Address
City State Zip City State Zip
Telephone 33(0 - &23 ZJ��2.& Fax Number 3' 14�O

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name .and street address
of the designated North Carolina Agee
Name
Current Mailing Address
City State zip
Telephone
E-mat! Address
Current Street Address.
City State Zip
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 dame. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
ddmrivo-rwata-t-ir►c0-embar ereait,eorn
Name of Registered Agent C-mall Address
Cate _T PA cK, STET
Current Mailing Address Current Street Address
am�4 N.G. 2728b
City State Zip City
State Zip
Telephone 33(o-623 �2626 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 attomey-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 informatiori should there be any change in the information .Provided herein.
M 1 Y5E LEMONS
Type or print name
Signature
AN FP,
Title or Authority
1�2 tc• �z .
Date
a Notary Public of the County of oG,� .
State of North Carolina, hereby certify that
appeared
Personally before me this day and being 2duXlys�wom �ackno�wledgedthat the above forrrrn was
executed by him.
Witness my hand and notarial sea[, this � day of 2p
PUIUC
- SM
UNIDA CARTER Nota
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tryC='s nf�see7'
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