NCC231114_FRO Submitted_20230419

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. The Alan Fink - Trustee Property, ET AL
1. Project Name
2
3
City or Township Mount Pleasant
Latitude 35.45770476614909 Longitude-80.4043731869483
Approximate date land -disturbing activity will commence: October 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Location of land -disturbing activity: CountyCabarrus
Highway/Street 10300 Fink Rd
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):
3.78
6. Amount of fee enclosed: $ 600 PAID . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac = $900.00).
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 Anthony Giordano E-mail Address [e-mail]
Telephone [phone] cell #
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Anthony & Marie Giordano 704-219-4665
Name Telephone Fax Number
3027 Pebble Creek Dr 3027 Pebble Creek Dr
Current Mailing Address Current Street Address
Stanfield, NC 28163 Stanfield, NC 28163
City
State Zip
10. Deed Book No. 15913
Page No.
City
163
State
91
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.
Trinity Land Development 1, LLC [e-mail]
Name
3027 Pebble Creek Drive
Current Mailing Address
Stanfield, NC 28163
City
E-mail Address
3027 Pebble Creek Drive
Current Street Address
Stanfield, NC 28163
State Zip City
Telephone [phone] Fax Number.
State
Zip

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:
nla
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:
Anthony Giordano
[e-mail]
Name of Registered Agent
E-mail Address
3027 Pebble Creek Drive
3027 Pebble Creek Drive
Current Mailing Address
Current Street Address
Stanfield, NC 28163
Stanfield, NC 28163
City State Zip
City State Zip
Telephone [phone] 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.
Anthony Giordano
Owner
Tye or print name Title or Authority
Signature Date
I, Ca'rr I 1Ca�jIYtSd a Notary Public of the County of S
State of North Carolina, hereby certify that nd en O appeared
personally before me this day and being duly swor acknowledged that the above form was
executed by him.
Witness my h��al►�r�tiMlgrial seal, this _day of 20_
�•�� �E �. R0ei,� �.
— Notary
0,�eaf UBL%C'
9 •, 03.23 26 s�, ��: My commission expires �3