NCC231411_FRO Submitted_20230531

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT 7)°,.12
No person may initiate any land-disturbing activity on one or more acres as covered by tl- °Ay---
and an acceptable erosion and sedimentation control plan have been completed and r
Quality Section, N.C. Department of Environmental Quality. Submit the completed foal, _.
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 MEADOWBROOK RV PARK PHASE
2. Location of land-disturbing activity: County POLK City or Township GREEN CREEK
APPROX 950 ON LT PAST MEADOWBROOK RD 35.2375° -81.98333°
Highway/Street Latitude(decimal degrees) LongltUde(decimal degrees)
3. Approximate date land-disturbing activity will commence:UPON APPROVAL
COMMERCIAL!RV PARK
4. Purpose of development(residential, commercial, industrial, institutional, etc.):
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 7.42
6. Amount of fee enclosed: $800.00 . 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 SCOTT ROACH E-mail Address [e-mail]
Phone: Office# 828-247-4495 Mobile# [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
MEADOWBROOK DEVELOPMENT,INC.a North Carolina Corporation 864-706-1604
Name Phone: Office# Mobile#
1211 Meadowbrook Road
Current Mailing Address Current Street Address
Rutherfordton NC 28139
City State Zip City State Zip
10. Deed Book No.360 Page No. 397-398 Provide a copy of the most current deed.
CELVED
ri Al 31 2U23
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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)maybe listed as the financially responsible party(ies).
MEADOWBROOK DEVELOPMENT,INC.a North Carolina CorporaUon [e-mail]
Company Name E-mail Address
1211 Meadowbrook Road
Current Mailing Address Current Street Address
Rutherfordton NC 28139
City State Zip City State Zip
Phone: office# Mobile# [phone]
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:
PAUL F. DECK, PRESIDENT [e-mail]
Name of Registered Agent E-mail Address
1211 Meadowbrook Road
Current Mailing Address Current Street Address
Rutherfordton NC 28139 _
City State Zip City State Zip
Phone: Office# Mobile# [phone]
Paul F. Deck
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office# Mobile# q^`p`4 1 u
Name of Individual to Contact(if Registered Agent is a company) MAR 31 2023
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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 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.
PAUL F. DECK PRESIDENT / REGISTERED AGENT
ie or print na Title or Authority
64.4 a-nay
3 /
nature Dat
1 B. SCOTT ROACH , a Notary Public of the County of RUTHERFORD
State of North Carolina, hereby certify that PAUL F. DECK 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 29 day of MARCH 23
B Scott Roach C-.(/(
NOTARY PUBLIC Notary
Rutherford County, NC
My Commission Expires June 08,2026 My commission expires June 8, 2026
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MAR 31 2023
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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 al!landowners.
Landowner 2 of Record:
FAIRWAYS OF POLK,LLC,a North Carolina Limited Liability Company [phone]
Name Phone: Office# Mobile#
1211 Meadowbook Road 1211 Meadowbrook Road
Current Mailing Address Current Street Address
Rutherfordton NC 28139-9140 Rutherfordton NC 28139-9140
City State Zip City State Zip
Deed Book No.397 Page No. 1 1 1 1 Provide a copy of the most current deed.
Landowner 3 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 4 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
City State Zip City State Zip
Deed Book No. Page No. Provide a copy of the most current deed.
Landowner 5 of Record:
Name Phone: Office# Mobile#
Current Mailing Address Current Street Address
C
City State Zip City State � Zip
Deed Book No. Page No. Provide a copy of the most current'd�ed:623
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