NCC223966_FRO Submitted_20221130

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 address or phone
number is unavailable, place NIA in the blank.)
Part A.
1
2.
3.
4.
5.
6.
Project Name Mills River Townhomes Single -Family Attached Development
Location of land -disturbing activity: County Henderson City or Township Mills River
Highway/Street Jeffress Road Latitude(decimaidegrees) 35.3992 Long itude(decimaidegrees) -82.5663
Approximate date land -disturbing activity will commence: November 2022
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 18.0
Amount of fee enclosed: $ 1800 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes Enclosed ❑ No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Roddey Jordan E-mail Address _rjordan(a),longbranchdevelopment_com
Phone: Office # 864-210-8400 Mobile #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Franklin Family Trust
Name Phone: Office #
368 Hoo ers Creek Road 2211 Jeffress Road
Current Mailing Address Current Street Address
Fletcher NC 28732
City State Zip
10. Deed Book No, 3837 Page No._
Mills River NC
City State
828-777-0129
Mobile #
28759
Zip
512 Provide a copy of the most current deed.

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
Franklin Family Trust
Name Phone: Office #
368 F.Ioopers Creek Road 2253 Jeffress Road
Current Mailing Address Current Street Address
Fletcher NC 28732 Mills River NC
City State Zip City State Zip
Deed Book No. 3837 Page No. 512 Provide a copy of the most current deed.
Landowner 3 of Record
828-777-0129
Mobile #
28759
Calvary fellowship of Western North Carolina Inc. 828-713-7825
Name Phone: Office # Mobile #
2035 Jeffress Road. 2035 Jeffress Road
Current Mailing Address Current Street Address
Mills River NC 28759 Mills River NC 28759
City State Zip City State Zip
Deed Book No. 1438 Page No. 656 Provide a copy of the most current deed.
Landowner 4 of Record:
Name
Current Mailing Address
Phone: Office #
Current Street Address
City State Zip City
Deed Book No. Page No.
Landowner 5 of Record:
Name
Current Mailing Address
Mobile #
State Zip
Provide a copy of the most current deed.
Phone: Office #
Current Street Address
Mobile #
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.

Part B.
1, Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owners) may be listed as the financially responsible party(Jes).
Mills River TH, LLC [e-mail]
Company Name E-mail Address
1855 E. Main Street, Ste 14-7
Current Mailing Address
1855 E. Main Street, Ste 14-7
Current Street Address
Spartanburg Sc 29307 Spartanburg Sc 29307
City State Zip City State Zip
Phone: Office #
864-210-8400 Mobile #
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
..............
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
Mills River TH, LLC [e-mail]
Name of Registered Agent E-mail Address
1855 E. Main Street, Ste 14-7 1855 E. Main Street, Ste 14-7
Current Mailing Address Current Street Address
Spartanburg Sc 29307 Spartanburg Sc 29307
City State Zip City State Zip
Phone: Office # 864-210-8400 Mobile #
David Benjamin Graves, Manager
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
Company RBA Name
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(s)
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 Party). I agree .to provide
corrected information should there be any change in the information provided herein.
Norman Louis Franklin
Type or print name
Signature
Trustee - Franklin Family Trust
Title or Authority
d� 2
Date
I,1CtclLSl�/ a Notary Public of the County of
State of North Carolina, hereby certify that appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this �1 day of 20 ZZ
Notary
Jlrc�tavy.�ukl�c My commission expires Lk�h
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(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed game.
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Registered Agent - Calvary Fellowship
Noel Hendrix of Western North Carolina_ Inc_._
Type or print name, Title or Authority
Signature
Date
I,lqtl VQ- iL S V , a Notary Public of the County of '&na�! 6 n
hereby certify that e &e rrC/r 1 X __appeared personally
State of North Carolina, y fy �, p Y
before me this day and being duly sworn acknowledged thatthe above form was executed by him/her.
Witness my hand and notarial seal, this % _day of UL-labe r^ , 20�
otary
My commission expires