NCC220685_FRO Submitted_20220216

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. Tony Garrett Site Development Project
1. Project Name
2. Location of land -disturbing activity: County Clay City or TownshipHayeSVIIIe
Highway/Street429 Hwy 69 Latitude35.03444 Longitude-83.8204
3. Approximate date land -disturbing activity will commence: April 1 , 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 27.0
6. Amount of fee enclosed: $2,080.00 . 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 Enclosedx
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Tony Garrett E-mail Address [e-mail]
Telephone Cell # 828-361-0712 Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Rebecca S. Garrett 828-389-9800
Name Telephone Fax Number
PO Box 72 4792 Old Hwy 64 W
Current Mailing Address Current Street Address
Warne, NC 28909 Warne, NC 28909
City State Zip City State Zip
10. Deed Book No. 00283 Page No. 0128 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.
PLC Service, Inc. [e-mail]
Name E-mail Address
PO Box 72
Current Mailing Address
Warne, NC 28909
City
4792 Old Hwy 64 W
Current Street Address
Warne, NC 28909
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
Telephone
E-mail Address
Current Street Address
State Zip 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:
Tony Garrett
Name of Registered Agent
PO BOX 72
[e-mail]
E-mail Address
4792 Old Hwy 64 W
Current Mailing Address Current Street Address
Warne NC 28909 Warne NC 28909
City
State Zip City
Telephone [phone]
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.
Tony Garrett Owner
Type or print name
Title or Authority
Signature Date
1,��1�ar • Ti — a Notary Public of the County of
State of North Carolina, hereby certify that lOr C appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this day of CA&(2r_ , 20�D l
SOVILLA R. HYATT
NOTARY PUBLIC
OP COUNTY
NORTH CAROL
MY COMMISSION EXPIRE
j�
ctw� L � - J �" -
Notary
My commission expires

ATTACHMENT A
9.1
Landowner(s) of Record (continued from page 1)
Sixty Four Partnership LLC
Name
Telephone Fax Number
P.O. Box 2628
Current Mailing Address
Current Street Address
Blairsville, GA 30514
City State Zip
City State Zip
10.1
Deed Book No. 300 Page No.
134 Provide a copy of most current deed.
9.2
Landowner(s) of Record (continued from page 1)
James A & Louis R Vander Woulde
Name
Telephone Fax Number
688 Grand Horizon Way
Current Mailing Address
Current Street Address
Franklin, NC 28734
City State Zip
City State Zip
10.2
Deed Book No. 283 Page No.
95 Provide a copy of most current deed.