NCC224043_FRO Submitted_20221209

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 NIA in the blank.)
Part A. Fonta Flora Trailhead @ Old Fort
1. Project Name
2. Location of land -disturbing activity: County McDowell city or Township Old Fort
Highway/Street TBD Bud Hogan Drive Latitude 35,632588 Longitude - 82.168591
3. Approximate date land -disturbing activity will commence: 8/15/2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Park
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 3A7
6. Amount of fee enclosed; $400 . The application fee of $65,00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is S585).
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:
NameAlex Gotherman
E-mail Address [e-mail]
Telephone [phone]
cell # 704-575-9000 Fax # NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
State of North Carolina
NIA NIA
Name
Telephone Fax Number
1321 Mail Service CTR
1321 Mail Service CTR
Current Mailing Address
Current Street Address
Raleigh NC 27699
Raleigh NC 27699
City State
Zip City State Zip
10. Deed Book No. 01321 Page
No 0162 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.
Town of Old Fort
[e-mail]
Name
E-mail Address
38 S Catawba Ave
38 S Catawba Ave
Current Mailing Address
Current Street Address
Old Fort NC 28762 Old Fort NC 28762
City State
Zip City State Zip
Telephone [phone]
Fax Number NIA

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
Telephone
State Zip City
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:
NIA
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.
Rick Hensley
Type or print name
Mayor
Title or Authority
9/27/22
Date
I, e_e r'r 1 e r a Notary Public of the County of L bow'e
State of North Carolina, hereby certify that -R i a appeared
personally before me this day and being duly sworn acknowledge that the above form was
executed by him.
Witness my hand and notarial seal, this e� 7 day of SeOCAIW , 20 a
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vxOTS R Notary
i My commission expiresL�
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