NCC230765_FRO Submitted_20230321

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1
Project Name Sparks Drive Commercial Building
2. Location of land -disturbing activity: County Rutherford City or Township Forest City
176 Sparks Drive 35.340273-81.899404
Highway/Street LatltUde(decimaldegrees) Long ltude(decimaldegrees)
3. Approximate date land -disturbing activity will commence: 1 0/01 /2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.45
6. Amount of fee enclosed: $ 200.00 . 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 ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Heidi Boring E-mail Address [e-mail]
Phone: Office # Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Haywood Equity Group Ltd. Partnership
Name
1820 Spencer Mountain Road
Current Mailing Address
Gastonia NC 28054
City State
10. Deed Book No. 2022
Phone: Office # Mobile #
Current Street Address
Zip City
Page No. 2660
State
Zip
Provide a copy of the most current deed.

(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 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.
Heidi Boring
Type or print name
S�mature
Manager
Title or Authority
Date
I, G� k-itej� , a Notary Public of the County of
State of North Carolina, hereby certify that M -1 n 80 R I N &r' 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 -7� day of
Notary
20 Y Z
My commission expires 4)VZ670o

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 owner(s) may be listed as the financially responsible party(ies).
RZ Forest City, LLC [e-mail]
Company Name E-mail Address
1437 Wintercress Court
Current Mailing Address Current Street Address
Marietta GA 30066
City State Zip City State Zip
404-895-9039
Phone: Office # 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. -
NC Corporate Connection, Inc
Name of Registered Agent E-mail Address
176 Mine Lake Court, Suite 100
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City
Phone: Office # 888-844-8360 Mobile #
Name of Individual to Contact (if Registered Agent is a company)
State Zip

Property Owner Authorization
Sparks Drive Commercial Building
176 Sparks Drive, Forest City, Rutherford County, NC 28043
Rutherford County Parcel #1636136
NCDEQ Erosion and Sediment Control Permit
III
I Ralph A. Dicksonof Haywood Equity Group Ltd. Partnership certify that I own the property
identified in this permit application, and thus give permission to Jack Featherston with RZ Forest City,
LLC to submit a draft erosion and sedimentation control plan and to conduct the anticipated land
disturbing activity.
AignatureOK4
lied Partnership, by its General Partner, Deerwood Investments,
Inc.
BY: � �ci �a
Date
aNotary Public ofthMounty of North Carolina ,State of
North Carolina, hereby certify that Ralph A. Dicksorappeared personally before me this day and
being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarized seal, this _Lqday of �lA-� , 20
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