NCC232859_FRO Submitted_20230927

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 _L i4'I vfidY
2. Location of land-disturbing activity: County gOARATI, Col City or Township 9_[11.,► ghtlae
Highway/Streeter Latitude '_$I.$61 Longitude 3.'• Lin
3. Approximate date land-disturbing activity will commence: k.� 5 L 70 2-7-
4 Purpose of development (residential, commercial, industrial, institutional, etc.):__AlrICy (,
5. Total acreage disturbed or uncovered�p (including off-site borrow and waste areas): 7 I
6. Amount of fee enclosed: $ Q0O • 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= 5900.00).
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: r+-
Name Q.-el se- La'tskmv\ E-mail Address n
1. iii1 M Ci9 @ V A'>u( -
Telephone lief— 71.0 -b 3_0/ Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rose&vluiAtko.1W4 in trotethi gat►rtU IAA pi q1Q-71,94so
Name Telephone Fax Number
erwtoN Gros Dr 'y0S tsl ss Isuti__CrOSS_Dr
Current Mailing Address Current Street Addre
tAiteF`vrcv'r NC. t_7_ '1_ w4-4. cvrasr NC. 2 7 s'V 7
City State Zip City State Zip
t 0 Deed Book No. 205 ( Page No. I ps Provide a copy of the most current deed.
Part B.
1 Company(ies) or firms) 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.
(1.046- li t.a 0141v1 'nutty 41ux:II L *a
Name E-mail Address
P12404 CWs Pr 8yo f r f o,i Cwrs Or
Current Mailing Address Current Street Addre s
Oo Kt fit /4 C Z 7 577 Wok rugs r n/e z 75-s?)
City Q State Zip City State Zip
Telephone C 11" 719"43O( Fax Number

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:
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
e) r L-0,01 a Lkklio 0 tea e)t
Typ r on t name 1144, Title or Aut ority
ig _iv.-_,:v±....:,42,t, ...,..z., 7 2,12 J
�` nature Date
9
I. tl.z4ice A- CI do -. a Notary Public of the County of A
State of North Carolina, hereby certify that 1?_c1bee tr perdttitta L 41Ltir,2 appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 41-4" day of s e --tr i h c r , 20 13
ELIZABE?H A CIELQ Cam✓ �'
Notary Public, North Carolina
Wake County of ry
Sexy Commission Expiros
April 03,2027
My commission expires rni f e l ji