NCC231420_FRO Submitted_20230516

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before this form
and art 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Y• 4C4L _
2. Location of land-disturbing activity: Counts _ City or Township MOCkSk. Q
Highway/Street,'0°� �t.lhllh'1C,Oari. Latitude(decimal degrees)26!1aQ tl OngitUde(decimaI degrees)CO.5 w
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential, commercial, industrial, institutional, etc.): QtASA hO"`
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):
6. Amount of fee enclosed 1 100.00 . The Express Permitting application fee is a dual charge.
The normal fee of$100.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
In addition,the Express Permitting supplement is$250 per acre up to eight acres,after which the Express
Permitting supplemental fee is a fixed$2,000.00 (Example:8.10-acre application fee is$2,900). Checks
should be addressed to NCDEQ.
Yes Enclosed No
7. Has an erosion and sediment control plan been filed? a [,� � ❑
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name N w'i EyCj,AS E-mail Address YYkaso11.
et
rs
Phone: Offiice# 1)3(4.`413,iyO0 Mobile# �O$
0
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
kl rs , �. �� � sob \AW\DA a1
City State Zip City State Zip
10. Deed Book No. Page No. I log, Provide a copy of the most current deed.

Part B.
1. Company(ies)who are financially responsible for the land-disturbing activity(Provide a comprehensive list
of all responsible parties on accompanied page.)If the company is a sole proprietorship or if the landowner(s)is
an individual(s), the name(s)of the owner(s)may be listed as the financially responsible party(ies).
Company Name E-mail A dress
(),q0:14,9 a\vd 7W3 C. Rtv Pv bkid•
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# 3(014I1'`k-toJ Mobile#
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
ItA0Y%A..ts !J` rnaL,)0.1 4\onnts,
Name of Registered Agent E-mail Add ess
Current Mailing Address Current Street Address
,uts ,,sue.., 01- alA06 1c`10.0w, tit- as to
City State Zip City State Zip
Phone:�� Office# 33( 41' •1400 Mobile# 3�C, . Coo g .ors-to
o
nn
k cs,e, U
Name of Individual to Contact(if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile#
Name of Individual to Contact(if Registered Agent is a company)
(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General

Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company DBA Name
(d) If order to facilitate Express Permitting, it is necessary to be able to contact the engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Engineering firm or other consultant E-mail Address
Individual contact person (type or print) Phone: Office# Mobile#
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(s)
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 Party). I agree to provide
corre d information should there be any change in the information provided herein.
c/ L. Fa,' i I),c.e._ PnC$"
rc451"
ype or intYSame Title or Authority
/7/Date
I, KA i, . vvtQyvN , a Notary Public of the County of ��,.,
State of North Carolina, hereby certify that l_Ryi s 1 ,r. appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this 1 day of c_\cant. , 20 aaa.
KATHY A MOWERY fC�"`" ,a IN1�LxsCr
Notary Public, North Caroline Notary
Forsyth County
M e gmmission Expires M commission expires M ,1„ a I ac�ato
arch 24,2026 Y p 1