NCC240611_FRO Submitted_20240301

Check if this project 1 in
E Y E D
Attach a copy of the Letter o
FINANCIAL RESPONSIBILITY/OWNERSHIP FORM S 01_
SEDIMENTATION POLLUTION CONTROL ACT 0 S�
1 �-FYE YIA�E�C�QNAL OFFICE
No person may initiate any land-disturbing activity on one or more acres as covered by t, c
activity under a common plan of development of this size as covered by the NCG01 permit, 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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
l. Project Name Latham Pool Products,Inc.
*If this project involves American Rescue Plan Act(ARPA)funds, list the Project Name or Project
Number(e.g., SRP-D-ARP-0121) below under which you were approved for funding through the
Division of Water Infrastructure (DWI).
Richmond Ci or Townshi Rockingham
2. Location of land-disturbing activity: County tY p
162 Enterprise Dr, 34.964422 Lpn Itude(declmaldagreea) 79.808212
Highway/Street Latitude(de«meI degrees) g
January 2024
3. Approximate date land-disturbing activity will commence:
4. Purpose of development(residential,commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered(including off-site borrow and waste areas):
i.98 acres
6. Amount of fee enclosed:$ 200.00 . The application fee of$100.00 per acre(rounded
up to the next acre)is assessed without a ceiling amount (Example: 8.10-acre application fee is$900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes 0 Enclosed © No 0
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name GI Arpi ITT E-mail Address Ji/AlIn7�® 1am ica14
Phone: Office#9O /772O63Z 6et Nip Mobile# q/0-33/-3683
9. Landowner(s)of Record(attach accompanied page to list additional owners):Latham Pool Products,Inc. 3OU S6q_6?00 30 y- 9/6-7 I i(� /
9
Name Phone: Office# Mobile#
176 Viking Dr. 176 Viking Dr.
Current Mailing Address Current Street Address
Jane Lew WI 26378 Jane Lew WI 26378
City State Zip City State Zip
10. Deed Book No. 1413 Page No. 001 Provide a copy of the most current deed.

Part B.
1. Company(les)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 landownerts)is
an i uividual(s),the names)of the owner(s)may be listed as the financially responsible party(les).
hom PE90 rock s, Zile. &ae&LJ0M
Company Name E-mail Address
i
°�8'� at-rend/el s uer ,�S 1.bZ i7¢r,�rise t
Current Mailing Address i < Current Street Address
/4tl pa My /2//O Irehi,zgz in Ale te39
City
State Zip City State Zip
11 p
�3800 Mobile: # 90 /O2 Obi '
Phone: Office#�g�J�33 .
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 consentfor 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:
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)
(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:
•
COY rci i°Oil Servi et (V►-n n y 5OP@ CsChlo6al.corn _
Name of Registered Agent E-mail Address
26,2h 6leinu old Oa-s-te 550 Z676 6/en wooct Aile sTe 550
Current Mailing Address Current Street Address
a2.c1Ce�` Ate 02 3 ba karpicl- n) a.
City State Zip City State Zip
Phone: Offico# O W-` 2 7-"r 30 Mobile#
Li 'irrnece
I
Nam:'of individual to contact(if Registered Agent is a company)

(c)lithe 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
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
corrected information should there be any change in the information provided herein.
Ott LUIS 6• her.77: _. T,l �lar� a r
Type or print e Title or Authority j
Date/it
Signet , itAxitz; Dat
I, ICI J Ea b Cl K i M , a Notary Public of the County of IRre:tiMvtip
State of North Carolina,hereby certify that .oSE matt Is C I I— A pa+J7C 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 2 day of Meues.ke - ,20-J-3
zistKijeong Kim '�
NOTARY PUBLIC Notary
Seal Richmond County ``
North Carolina My commission expires I '-/ I" /")--.''1_r—
My Commisskan Expires December 10.2025