NCC240471_FRO Submitted_20240220

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. L-0 I" 113/1' L ih5a7�
1. Project Name -
2. Location of land-disturbing activity: County i ► r, City or Township teu)15
Highway/Street i s 5 1O(►be Latitude 36' /05 Z Longitude Ve)'`NW
3. Approximate date land-disturbing activity will commence: 1/147Pii
4. Purpose of development(residential, commercial, industrial, institutional, etc.): f BSI
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 4,50
6. Amount of fee enclosed: $ 14O,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 ✓nt No Enclosed
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name 1O51IA-6\ j 1cc1 E-mail Address '0514' rice'b4ckr5
Telephone 2);6-1 qz—6,1 b t) Cell# 336 Ptg" Z—5160 Fax# �'l4
9. Landowner(s)of Record (attach accompanied page to list additional owners):
A;cc; 13,„.:13t1-5 it„Nte,,„,../- /VA-
Name yy�� Telephone r, Fax Number
✓ 63 /
Current Mailing Add ss Current Street Addreis
i3ete.)> G, 1z wL 7-1-e ii Pe s G /('( z' 009
City State Zip City State Zip
10. Deed Book No. DO &19 Page No. cz✓;314 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.
1- ,
017ar. 6;GG. `djin C (i46 K►ihrs ,Co'M
Name E-Ail Address
551 1urit RA . 65( �Jrl� iCJC
Current Mailing Address Current Street Address
1,J,t„s1 ,5wl r iV 217Ity k.vsfm S046 e..4iott
City State Zip City �n State Zip
'�77
Telephone `7 3 14Z -5/6 d Fax Number A174

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.
,(C-c, V P Orr vas
Type or print name Title or Authority
S' nature Date
SEPTEMBER A.HARPER , a Notary Public of the County of f`
State of North Carolina, hereby certify that S QSh Q :i(c , appeared
personally before me this day and being duly s m cknowledged that the above form was
executed by him. /
Witness my hand and notarial seal, this /6 day of e,h�,,_ , 20 ,�1�
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