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Home My WebLink AboutNCC240116_FRO Submitted_20240202 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. WAX r • 1. Project Name Y�/AX1.1 AW -1-1\II)IA N TO:4 IL,. L.oT5 / — 4 2. Location of land-disturbing activity: County 1.)N) I o te! City or Township WA 14A \/V Highway/Street WA)ct-}11w.-N(),,t4t Latitude ;g6$'7i 33 Longitude $D,"7O$631 _ 3. Approximate date land-disturbing activity will commence: 612512 - 4. Purpose of development(residential,commercial, industrial,institutional,etc.): Tea r fj-e.N Tr/{L 5. Total acreage disturbed or uncovered(including off-site borrow and waste areas): 5-. 7 2-AC Ee5 6. Amount of fee enclosed: S AQ 0 . 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 V 8. Person to contact should erosion and sediment control issues arise during land-disturbing activity: Name —10 NY I4e..I2.6eg 7 E-mail Address Tkeg&e.irre t1 P14HOh1Z5 LL C,Gal-, e Telephone N//r4 Cell# -410"F4 -1 ZF� � � Fax# NIA. 9. Landowner(s)of Record (attach accompanied page to list additional owners): — P�i4. TAGt-I 0 Name Telephone Fax Number 1 3O5 V./y iv H tix 5 a" Dg. 1305 'YNil-I 7i$$T D 17.- _ Current Mailing Address Current Street Address WA I-4A IV N. 0 2F1'79 w,4Xt.+Aw ' (I 2'tft City State Zip City State Zip 10. Deed Book No. `J 550/ Page No. 5 ci q 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 fisted as the financially responsible party. 6e,bVsc-1 5 t..r4 6.e.viC_'e' SAL .5 '/, r-Jb0,. G:2F-d Name E-mail Address 1305 WyNt?-Vtz.5-rDry 10,5 WWNwL./i . r ) R Current Mailing Address Current Street Address City State Zip City State Zip Telephone ` L ' 1->6 —i 6r'b7 Fax Number i I - 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: , M1R NIA . Name E-mail Address 144 NL Current Mailing Address Current Street Address N NIA City State Zip City State Zip Telephone Fax Number N I (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: NLAL NIA • Name of Registered Agent E-mail Address Ni/4 I"Ni Let, Current Mailing Address ` Current Street Address /Z` )A City State Zip City State Zip Telephone t�iA. Fax Number rd 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.6 e. .-" r�A. ^LI CC.cg 0 w/vet Type or print me Title or Authority l2JIJZ3 . Signature Date 1, 1e "rct,.{(c r , a Notary Public of the County of V I n 1 O' State of North Carolina, hereby certify that Geer-T., J `'� t cCO appeared personally before me this day and being duly swots acknowledged that the above form was executed by him.Witness my hand and notarial seal,this 11., day of Vet-e,mbt,r , 20 2� ,`` ttttt►nnnpttt t4:{jAitia- ,... %Z��( TAYLO,' Notary Q;+01AR} My commission expires �v A Z� ZaZS My Comm.Exp. a 0712712025 , 'i".'4UB ..\C':. ::'--- ,,,,,U U tIIU",,,, Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple owners. Attach copies of this page as needed to list all landowners. Landowner 2 of Record: -TA Ne- .�'A1,,Gc:V, '164 � %, 50 2 713a,1752TV Name Phone: Of€ic # Mobile# I-I op(e. geD5 Wy/J i-n ',z T Dig - -i 3o- buy"0 ut ► Dr - Current Mailing Address Current Street Address './ PA x 14Auf iNic 2✓ i 1 WA tv 1\, C 9) 13 City State Zip City State Zip Deed Book No. cS S 0 I Page No. 5 qR Provide a copy of the most current deed. Landowner 33/of Record: C... g- 4Od4.7 5,,� 1,i6co Q`72-�53/• -i2�' l 7-,q t- 56O� Name tt _ }/ ��yt1 ) �J Phone:/f_ 1Office#�J / 1} /�Mobile#jam 2bl FO iJ 6.; i ,A4.h PL, '1a( i iou4i4 ! I4LLPE - Current Mailing Address Currenttt Street Address USA% , w NI C z$ i'�?7_ V A X HA w ki,C ,.gg3'1 7 3 City State Zip City State Zip Deed Book No. V 5 o i Page No. 5 q q Provide a copy of the most current deed. Landowner 4 of Record: E1Z“A -,4 Licc0 104 -14b2-6r7g?' 1,Z -c'ir=5,21' Name Phone: Office# _ i Mobile# 1 2 f i P -L,6 14- .)0 6 ) Ko u 6'4 l 2, Current Mailing Address Current Street Address WA 7cN4 w K1 ,C .Z 5173 WA?<H Lt> K1 C 2g I '__ City State Zip City State. Zip Deed Book No. 1 5 01 Page No. 5 11 q Provide a copy of the most current deed. Landowner 5 of Record: NI/A NiA NJA Name Phone: Office# Mobile# hi) A N l,_ k)1A . Current Mailing Address Current Street Address "LA NIA "4/ ' City State Zip City State Zip Deed Book No. t4/A Page No. M)il Provide a copy of the most current deed. ce geg 12 26.2.3 N e A Li 4 c;Q,.� t7,e 1 D t iv G i4 T 1345 WAN 1-11ig ; g. 291 r1 G. RA.NT Geog& e J- Lrccey �eg►dl1S,51ortl T' e L 'ehl t 1-4 b t-74)4.7 Pl0paeP LAt1p Q is T vgi3ANCe Acnviry aN t-ty 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. 5i4 L t c c e � Type or print nam Title or Authority GC' t�� ►��a7 • gnatur(e Date c.!, \� Ta- l r ,a Notary Public of the County of U'n (D el A e- State of North Carolina, hereby certify that Sa- Sct. LGp 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 Z day of ,20 Z3 ��{ - - O ,` Notary s�ai" ,.p oTAR 37)0� 72 2a2 3 � � My commission expires 1/ i My Comm.Exp. 0712712025 ; PUB LNG,112 2 De cem&eg 12 Z 'Z 3 _..`-7g_ecv cc:.o 121eSzDING .4T 1 624NT Geode J- 5ALacTcc, tZ1-t►5.SIC+ A � i-tt\J NC IA � �lJ �f 4 l� trrt r�f '�d cr fsl 1 U .y Pg-D po e LAN 17 �? t 5 i vgr3A N Ce Ac�-ivrry at-) Hy rife 1 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. 6-.1zeccirZy 5A lit c.. 61_0 Ie Type or print na� - Title or Authority I I2I x 3 Signature Date j f I, ,Th � e`( ,a Notary Publiccof`the County of U '1 t LA. State of North Carolina, hereby certify that C�1J xt 1`C (_ appeared personally before me this day and being duly sworn acknowledgedhat the above form was executed by him. Witness my hand and notarial seal, this day of 20 L ig(D1* , , ., N S."(3�6'4 ,,,,, tart' I - '�.� My commission expires 1V�-ttJ 2.7 AQTARy• • F. My Comm Exp. , 07/272025% _ p.- %`. AUBL\V :v r De fe_t+- 13eg 12 2o.Z 3 <5/11...1cc() 12s1DitvGAT 24 T GeogGe (I 5ALicco (zM)$ icN A The 1.QA i A L 'Fe e N` -t i`l 1-4 do PIZD p 5e P LAN !? Q 15 i vo3ANce AcrnVi Ty ON HY ref—'., 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. 4,4 Type or print name Title or Authority S � f ) 2-)23 Signature I Date I, ;I-C.\( 'caVLo r ,a Notary Public of the County of U n‘0 n L State of North Carolina,hereby certify that C'r Cct. Sock CC 05 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 1 day of e e zegf-- ,20 Z 7 ,,,,,,,q„u pp, TAY(,4,,,, Notary r' �}+� � - My OI ''�i t V` �V �OTa My commission expires1 , ; 07t2712025 , - PUBOCI 1. °uo, COUP'' ,,,,,