NCC215496_FRO Submitted_20211005

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.
Project Name: La Grange 151 ac Yard
2. Location of land -disturbing activity: County Lenoir City or Township_ Moseley
Highway/Street US Highway 70 Latitude 33.2722 Longitude-77.7374
3. Approximate date land -disturbing activity will commence: June 15, 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 141 acres
6. Amount of fee enclosed: $_9,165 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 $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 Wayne Hogden _ E-mail Address [e-mail]
Telephone Cell # 903-804-9318 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Co art of Connecticut Inc. 972.391.5400
Name Telephone
Fax Number
14185 Dallas Parkway, Suite 300 14185 Dallas Parkway, Suite 300
Current Mailing Address Current Street Address
Dallas TX 75254 Dallas TX 75254
City State Zip City State Zip
10. Deed Book No
Part B.
20
Page No. 66 Provide a copy of the most current deed.
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.
Co art of Connecticut. Inc Eric.TrumbacKDcogart.com
Name E-mail Address
14185 Dallas Parkway, Suite 300
Current Mailing Address
Dallas TX 75254
City State Zip
Current Street Address
City
State
Zip

Telephone [phone] Fax Number
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:
Gregory DePasauale re .de as uale co art.com
Name E-mail Address
2626 Glenwood Avenue, Suite 550 Same
Current Mailing Address Current Street Address
Raleigh NC 27608 _Same
City State Zip City
Telephone [phone] Fax Number NIA
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. It the Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent
Current Mailing Address
E-mail Address
Current Street Address
City State Zip City
Telephone Fax Number
State Zip
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.
Greg DePasquale
Type or print name
�"JJ d
Signature
State of Texas, hereby
personally before me this
executed by him.
Secretary
Title or Authority
6/25/2021
Date
I
a Notary Public of the County of
certify that appeared
day and being duly s orn acknowl dged that the above form was
Witness my hand and notarial seal, this day of a 20��
a
AMY CLARK
Notary ID #11952999 Notary
ly Commission Expires
a August 27, 2024
My commission expires

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