NCC232485_FRO Submitted_20230817

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 1 i mberlund Furmr, ^ �0 5 �l 1�- �5��6,`1�-��'�{ SS gc %
2. Location of land-disturbing activity: County n0 •2. City or Township t.ke.,\-rho (-( -\c.
�-V(,lr.iry Ft
. 00'SGiSweC4- �(-\ J I� V Highway/StreetGrinhrtur' Crr
e1 Latitude 55 . \\ 0 Longitude
3. Approximate date land-disturbing activity will commence: c)5 / 1,0 )3
4. Purpose of development(residential, commercial, industrial, institutional, etc.): 9Ne,St z&2,r
(( �1ciu►,
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): d(ALA
6. Amount of fee enclosed: $ ( 0 t) . 00 . 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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name -I-11e,r Vavv-, E-mail Address A-d.Uvi", ,(1\(,, eC O'r\c5r\(# m
Telephone "\l u`-Y1 - o'7 Cell# NI pc Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners):
1N(.\ e O Tres Lt-L N Ni P�
Name Telephone Fax Number
1/\1-0 Cti kWY'S \Z�,Svatic st1k) r91-b`4j Sk cork,, CZ-� Su���c (6\0
Current Mailing Address Current Street Address
VCA9-% L L1 bO`1 ( -U1e i�� N C- ©`.1
City State Zip City State Zip
10. Deed Book No. 1 �') Page No.O`?-5 k((Wei,till 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.
M(.key \-\ow't5 LI.L kdv,v; cprA(,k-ccht) e,sn(..c,ur�
Name E-mail Address
{, -,`,< tx.iYc %1O T-cork. ) '9- vorc. �� )
Current Mailing Address Current Street Address
0-Mt,i 9-. N C, L`1 lo\ 9--(Alc«.,h N1 C, -)-70`t
City State Zip City State Zip
Telephone G 1 Ct 7 v1 b\7 Fax Number \\I