NCC232635_FRO Submitted_20230831

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: EB-5938-Book Walk-South
2. Location of land-disturbing activity: County: Catawba City or Township: Hickory
Highway/Street 4`h St Dr SW Latitude 35.721806 Longitude-81.345484
3. Approximate date land-disturbing activity will commence: Fall 2021
4. Purpose of development(residential, commercial, industrial, institutional, etc.): Greenway
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 2.55
6. Amount of fee enclosed: $195 The application fee of $65.00 per acre (rounded up to the next acre) is
assessed without a ceiling amount (Example: a 9-acre application fee is$585).
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 Tori Golaszewski E-mail Address Tori.Golaszewski(a)kimley-horn.com
Telephone [phone] Cell# Fax#
9. Landowner(s)of Record (attach accompanied page to list additional owners):
Ibiza LLC
Name Telephone _ Fax Number
PO Box 3331 PO Box 3331
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 3305 Page No. 0650 Provide a copy of the most current deed.
Part B.
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.
City of Hickory-Engineering Department kwinklerRhickorync.gov
Name E-mail Address
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip

Telephone [phone] Fax Number
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:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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.
//-1,eR qt/7)1 C/7)/ 14/1/4-6.ER
Type o. p ' t me Title or Authority
6/4e/at
Signature Date
I, Cv9c1? 1AMAcvj , a Notary Public of the County of "
State of North Carolina, hereby certify that 1�0A el Mi(.t.t"12— 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 2aY of ( , 20 21
CRYSTAL B MUNDY CU!423164A+
NOTARY PUBLIC
Catawba County Notary
Seallorth Carolina I
My Commission Expires 12ti
My commission expires I ( 02I To ZZ

9. Landowner(s) of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 2719 Page No. 0094 Provide a copy of the most current deed.
10. Landowner(s)of Record (attach accompanied page to list additional owners):
City of Hickory
Name Telephone Fax Number
PO Box 398 PO Box 398
Current Mailing Address Current Street Address
Hickory NC 28603 Hickory NC 28603
City State Zip City State Zip
10. Deed Book No. 3607 Page No. 0545 Provide a copy of the most current deed.