NCC216559_FRO Submitted_20211123

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A. Broadpointe Industrial Facility
1. Project Name
2_ Location of land -disturbing activity: County Henderson City or Township Mills River
Highway/Street 684 Broadpointe Dr. Latitude 35.425583 Longitude-82.554972
3. Approximate date land -disturbing activity will commence: 1 1 /01 /2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 7.17
6. Amount of fee enclosed: $ 520 . 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
David Gibbons
david@bun rootis.eom
Name
E-mail Address
Telephone [phone]
Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Minkles Broadpointe II,
LLC 214-616-0652
Name
Telephone Fax Number
7 Cherrywood Road
7 Cherrywood Road
Current Mailing Address
Current Street Address
Locust Valley NY
11560 Locust Valley NY 11560
City State
Zip City State Zip
10. Deed Book No. 3749
Page No. 453-457 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.
Minkles Broadpointe II, LLC
[e-mail]
Name
E-mail Address
7 Cherrywood Road
7 Cherrywood Road
Current Mailing Address
Current Street Address
Locust Valley NY
11560 Locust Valley NY 11560
City State
Zip City State Zip
Telephone [phone]
Fax Number NIA

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:
Gregory D. Hutchins
Name
301 College Street, Suite 400
[e-mail]
E-mail Address
301 College Street, Suite 400
Current Mailing Address Current Street Address
Asheville NC 28801 Asheville NC 28801
City
State Zip
Telephone [phone]
City State Zip
Fax Number N/A
(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:
Gregory D. Hutchins [e-mail]
Name of Registered Agent
301 College Street, Suite 400
Current Mailing Address
Asheville NC 28801
City
State Zip
Telephone [phone]
E-mail Address
301 College Street, Suite 400
Current Street Address
Asheville
City
Fax Number N/A
NC 28801
State Zip
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.
David Gibbons
Type or print name
Signature
Manager
Title or Authority
a
Date
I, f ���.(
a Notary Public of the County of S
State of hereby certify that >> cz S 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 day of O + TO 6t" , 20�_
VLpal y
Seal
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