NCC224116_FRO Submitted_20221216

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 and/or fax information
unavailable, place NIA in the blank.)
Part A.
Project Name Townhomes At Brookshire Phase 26
2. Location of land -disturbing activity: County Watauga City or Townshi
Highway/Street Brookshire Road Latitude 36 13'56" N Longitude 81 38'56"W
3. Approximate date land -disturbing activity will commence: 02/01/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc -):Residential
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_ 12.5
6_ Has an erosion and sediment control plan been filed? Yes No Enclosed X
7. Person to contact should erosion and sediment control issues arise during land -disturbing activity'
Name Rick Miller
Telephone [phone] Cell #
E-mail Address moina.bellsouth.net
Fax #
8_ Landowner(s) of Record (attach accompanied page to list additional owners):
RCPBD Investments, LLC
Name
PO BOX 3018
Current Mailing Address
828-265-6344
T—elephone Fax Number
324 NC Hwy 105 Ext. Suite 1
Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City State Zip
9_ Deed Book No._2095 Page No. 675 Provide a copy of the most current deed_
Part B.
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 msponsibte party.
RCPBD Investments LLC
Name
PO BOX 3018
Current Mailing Address
28-265-6344
Telephone
324 NC Hwy 105 Ext. Suite 1
Current Street Address
Fax Number
Boone NC 28607 Boone NC 28607
City State Zip City 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:
ame
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:
Rick Miller
Name of Registered Agent
PO Box 3018
Current Mailing Address
m i bells uth.net
E-mail Address
324 NC Hwy 105 Ext. Suite 1
Current Street Address
Boone NC 28607 Boone NC 28607
City State Zip City 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 attomey-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.
T or rir7vt
me ll Title or Authorit
Signature Date
a Notary Public of the County of
State Of North Carolina, hereby certify thatRnGj N1,1t1.Q/� �� 'W g �c ppeared s5� �)
LL"G
personally before me this day and being duly sworn acknowledged that the abo a form was executed
by him_
Witness my hand and notarial seal, this—LOL—day of 0 CI t v , 20
S T ACY L. ELDRETH
Notary Public, North Carolina
Watauga County
My Commission Expires Notary
Novernber 16, 2023
My commission expires_