NCC230027_FRO Submitted_20230105

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.
1. Project Name
H&E Equipment Services 612 Canterbury Road Site Renovation
2. Location of land -disturbing activity: County Gaston City or Township Kings Mountain
Highway/Street Canterbury Road Latitude 35.23648 Longitude -81,31777
3. Approximate date land -disturbing activity will commence: 11-15-22
4. Purpose of development (residential, commercial, industrial, institutional, etc.): commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 2.5
6. Amount of fee enclosed: $ 300 . 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).
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 George Richards E-mail Address [e-mail]
Telephone Cell # 919-608-7500 Fax #
a
Landowner(s) of Record (attach accompanied page to list additional owners):
HE Kings Mountain LLC 225-924-7206
Name Telephone
450 Main Street
Current Mailing Address Current Street Address
Baton Rouge, Louisiana 70801
City State
10. Deed Book No. 5145
Part B.
Zip City
Page No. 939
State
Fax Number
Zip
Provide a copy of the most current deed.
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.
HE Kings Mountain LLC [e-mail]
Name E-mail Address
450 Main Street
Current Mailing Address
Baton Rouge, Louisiana 70801
City
Current Street Address
State Zip City
State
WE

Telephone [phone] Fax Number 225-924-1235
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:
CT Corporation
Name
160 Mine Lake Ct, Ste, 200
Current Mailing Address
Raleigh, NC 27615
City State
Telephone
E-mail Address
Current Street Address
Zip City
Fax Number
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. 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 State
Telephone
E-mail Address
Current Street Address
Zip 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.
Carolyn E. Martin
Type orrint name
_r..
Si ure
I Andrew T. McMains
Manager
Title or Authority
12/6/2022
Date
Parish
a Notary Public of the eounlyy-of East Baton Rouge
Louisiana
State of Pfo-rth-Earditrra, hereby certify that Carolyn E. Martin 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 8th day of December , 20 22
a Andrew 1, Mains
Notary Public - Louisiana
y commission is for Life
LA bar Roll No. 2364
Notary
My commission expires At Death