NCC220957_FRO Submitted_20220322

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Greenheck King's Mountain DOAS Expansion
2. Location of land -disturbing activity: County Cleveland City or TownsH7Kings Mountain ETJ
Highway/Street 212 Commerce Blvd Latitude 35.2410 N000 Longitude 81.4100 W
3. Approximate date land -disturbing activity will commence: 03/01/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 4.5
6. Amount of fee enclosed: $ 1,750.00 . The Express Permitting application fee is a dual
charge. The normal fee of $100 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Choate Construction E-mail Address [e-mail]
Telephone [phone] Cell # 919.422.7859 Fax # N/A
9. Landowner(s) of Record (attach accompanied page to list additional owners)
Greenheck Real Estate, LLC
715-355-6420
Name
Telephone Fax Number
1100 Greenheck Drive
Current Mailing Address
Current Street Address
Schofield WI
54476
City State
Zip
City State Zip
10. Deed Book No. 1652
Page No. 135 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.
Greenheck Fan Corporation
[e-mail]
Name
E-mail Address
1100 Greenheck Drive
Current Mailing Address
Current Street Address
Schofield WI
54476
City State
Zip
City State Zip
715-355-6420

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:
CT Corporation System
Name
160 Mine Lake Ct, Ste 200
Current Mailing Address
Raliegh NC 27615-6417
City
E-mail Address
Current Street Address
State Zip City
Telephone [phone]
Fax Number
State Zip
(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
Current Mailing Address
City
Telephone
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
Burton Engineering Associates [e-mail]
Engineering Firm or other consultant E-mail Address
Matthew Graham 704-553-8881
Individual contact person (type or print) Telephone
N/A
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.
Richard M. Totzke
Typ r ri e
T1
Sig ature
Chief Operating Officer & Treasurer
Title or Authority
February 18, 2022
Date
Kristine K. Rodehaver a Notary Public of the County of Marathon
Wisconsin
State of Nee##-Gafelina, hereby certify that Richard M. Totzke appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial jollmp 18th day of February 12022
���E K: RDaFr� ��C�� �_nkL6:�4
..Kristine K. Rodlehaver
Seal ��� NO TaRr
0 '-� � My commission expires 01/28/2025
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