NCC242414_FRO Submitted_20240812

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 South Battleground Skilled Nursing Home
2. Location of land-disturbing activity: County Cleveland City or TownshipKlrlgs Mountain
Highway/Street 726 South Battleground Ave. Latitude 35.176970 Longitude-81 .428230
3. Approximate date land-disturbing activity will commence:05/01/2024
4. Purpose of development (residential, commercial, industrial, institutional, etc.):Commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 1 .21 ac
6. Amount of fee enclosed: $ 1 ,200 . The application fee of $100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8.10 ac= $900.00).
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 Brian Hill E-mail Address [e-mail]
Telephone [phone] Cell# Fax#
9. Landowner(s) of Record (attach accompanied page to list additional owners): SEE ATTACHMENT
Peak Realty Cleveland, LLC
Name Telephone Fax Number
101 Baines Court 101 Baines Court
Current Mailing Address Current Street Address
Cary NC 27511 Cary NC 27511
City State Zip City State Zip
10. Deed Book No. 1 893 Page No. 1387 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.
Peak Resources [e-mail]
Name E-mail Address
101 Baines Court 101 Baines Court
Current Mailing Address Current Street Address
Cary NC 27511 Cary NC 27511
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:
Brian Hill [e-mail]
Name of Registered Agent E-mail Address
101 Baines Court 101 Baines Court
Current Mailing Address Current Street Address
Cary NC 27511 Cary NC 27511
City State Zip City State Zip
Telephone [phone] 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.
Brian Hill President
'liype r print a)ne Title or Authority
.11" 21 11
S� a Date
I, Act.>'�tom. ln� t� D � , a Notary Public of the County of at,e
State of North Carolina, hereby certify that 1 ; KJA, l4: t I 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 '-t day of , 20 al
Notary
LION W. JONES
Notary Public,North Carolina My commission expires a q(3 02.b
Lee County
My Commission Expires
Se.tember 30 2027

PIN #2572570228
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Liquid Management, LLC
Name Telephone Fax Number
231 Post Office Dr, Suite B-8 231 Post Office Dr, Suite B-8
Current Mailing Address Current Street Address
Indian Trail NC 28079 Indian Trail NC 28079
City State Zip City State Zip
10. Deed Book No. 1893 Page No. 1211 Provide a copy of the most current deed.
PIN #2572362809
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Dongfanghong, LLC
Name Telephone Fax Number
700 South Battleground Ave 700 South Battleground Ave
Current Mailing Address Current Street Address
Grover NC 28073 Grover NC 28073
City State Zip City State Zip
10. Deed Book No. 1870 Page No.2065 Provide a copy of the most current deed.