NCC217106_FRO Submitted_20211222

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 N/A in the blank.)
Part A. Appalachian Rare Plant Lab Site Plan
1. Project Name
2. Location of land -disturbing activity: County Burke City or Township Jonas Ridge
Highway/street Mortimer Road Latitude 35.975969 Longitude -81.891929
3. Approximate date land -disturbing activity will commence: Fall 2021 It Spring 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.86
6. Amount of fee enclosed: $ 130 . 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 James Coke E-mail [e-mail]
Telephone [phone] cell # 828-334-6559 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
James Coke 828-334-6559
Name Telephone Fax Number
P.O Box 252 8251 Hollow Pine Trl
Current Mailing Address Current Street Address
Jonas Ridge NC 28641 Newland NC 28657
City State Zip City State Zip
10. Deed Book No. 2525 Page No. 217 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.
James Coke [e-mail]
Name E-mail Address
P.O Box 252
Current Mailing Address
Jonas Ridge NC
City
8251 Hollow Pine Trl
Current Street Address
28641 Newland NC 28657
State Zip City
Telephone [phone] Fax Number
State
Zip

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
Current Mailing Address
City State Zip
Telephone
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City
Telephone
State Zip
E-mail Address
Current Street Address
City State Zip
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.
James Coke
Type or print name
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Title or Authority
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Date
I. , a Notary Public of the County of �,cck•{-�
State of North Carolina, hereby certify that :: r & e 5 [�lJ �� appeared
personally before me this day and being duly swam acknowledged that the above form was
executed by him.
Witness my hand and 'al seal, this day of , 20
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ALL E�
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