2018-277 Planning - NCDEQ financial responsibility acceptance form

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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. Bonnie Hammersley County Manager Type or print name Title or Authority Signature Date ------------------------------------------------------------------------------------------------------------------------------------ 1, ;1 zt // , a Notary Public of the County of State of North Carolina, hereby certify that appeared personally before me this day and being duly sworn acknowledged tlit the above form was executed by him. Witness my hand and notarial seal, this le day of jLdu 20 / .'S' 't-��`'°�:r��f(y`ItL's:ti aer• � r u cr i xd�•R:./yam�� a F` Notary Seafifi O ' 31- .` �fr ',-FPO E My commission expires r= I