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HomeMy WebLinkAboutNCC241414_FRO Submitted_20240515 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, including any activity under a common plan of development of this size as covered by the NCG01 permit, 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 NameASHEOUT - Starbucks *If this project involves American Rescue Plan Act (ARPA) funds, list the Project Name below under which you applied for funding through the Division of Water Infrastructure (DWI). 2. Location of land-disturbing activity: County Randolph City or TownshipAsheboro E. Dixie Drive 35.701093 -79.785179 Highway/Street • Latltude(decimal degrees) Longitude(decimal degrees) 3. Approximate date land-disturbing activity will commence. May 15, 2024 4. Purpose of development(residential, commercial, industrial, institutional, etc.):Commercial 5. Total acreage disturbed or uncovered (including off-site borrow and waste areas). 0.74 6. Amount of fee enclosed: $1 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 Matt Patrick E-mail Address mpatrick@geminiconstructionco.com Phone: Office# 706-863-2222 Mobile# 706-564-1228 9. Landowner(s) of Record (attach accompanied page to list additional owners): Ashe Out, LLC 706-434-1759 Name Phone: Office# Mobile# PO Box 204227 1190 Interstate Parkway Current Mailing Address Current Street Address Augusta, GA 30919-4227 Augusta, GA 30909-6404 City pState Zip City State Zip 10 Deed Book No.2788 Page No. 1 452 Provide a copy of the most current deed 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). Ashe Out, LLC cstratton@hullpg.com Company Name E-mail Address PO Box 204227 1190 Interstate Parkway Current Mailing Address Current Street Address Augusta, GA 30919-4227 Augusta, GA 30909-6404 City State Zip City State Zip Phone: Office# 706-434-1759 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: Corporation Service Company sop@csglobal.com Name of Registered Agent E-mail Address 2626 Glenwood Ave Ste 550 Same Current Mailing Address Current Street Address Raleigh, NC 27608 City State Zip City State Zip Phone: Office# Mobile# Name of Individual to Contact(if Registered Agent is a company) (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. James M Hull Manager, Ashe Out, LLC ,e or print nai e Title or Authority -447/24 03I2oaY ,nature / of Date r I, U N E (.)in.AC fug no) , a Notary Public of the County of CO(0m-12 iA State of Georgia, hereby certify that -0 r-)'t,Ls ,f J ,)1( appeared personally before me this day and being duly sworn acknowledged that the above form was executed by him/ her. Witness m` e. �tarial seal, this 2-3cA day of Al{, 1` , 20 Z Z.• J . J o-CA� FE; tary Q I • 0 pUB'.- r �, My commission expires (0 3z 1 -D 15 0 •. : -'-': ' II .,''Ge'A.GOJa`�