NCC217005_FRO Submitted_20211217

FINANCIAL RESPONSIBILITYIOWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
EXPRESS PERMITTING OPTION
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 Bumgarner Site
2. Location of land -disturbing activity: County Wilkes City or Township Wilkesboro
Highway/StreetH. Anderson Road Latitude36.138719 Longitude-81.095889
3. Approximate date land -disturbing activity will commence: Jan. 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 10.32
6. Amount of fee enclosed: $ 2000 + 715 = 2715 . The Express Permitting application fee is a dual
charge. The normal fee of $65.00 per acre (rounded up to the next acre) is assessed without a ceiling
amount. In addition, the Express Permitting supplement is $250.00 per acre up to eight acres, after
which the Express Permitting supplemental fee is a fixed $2,000.00 (Example: 9 acres total is $2,585).
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 Terry Bumgarner E-mail Address b1 [e-mail]
Telephone Cell # 336-416-1740
Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Bumgarner & Bumgarner, Inc. 336-416-1740
Name
Telephone Fax Number
PO Box 1015
3204 Stateville Road
Current Mailing Address
Current Street Address
Wilkesboro, NC 28697
North Wilkesboro, NC 28659
City State
zip City State zip
10. Deed Book No. 677
Page No. 637 Provide a copy of the most current deed.
Part B.
1. Company (iss) or firm(s) who
are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) !f the company or firm is a sole
proprietorship, the name of the owner or manager may be listed as the financially responsible party.
Bumgarner & Bumgarner, Inc. [e-mail]
Name
E-mail Address
PO Box 1015
3204 Stateville Road
Current Mailing Address
Current Street Address
Wilkesboro, NC 28697
North Wilkesboro NC 28659
City State
Zip City State Zip

Telephone [phone] Fax Number
(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
Current Mailing Address
city
Telephone
State Zip
E-mail Address
Current Street Address
City State Zip
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
Current Mailing Address
City State
Telephone
E-mail Address
Current Street Address
Zip City State Zip
Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
BREC, PA
Engineering Firm or other consultant
Justin Church, PE
Individual contact person (type or print)
[e-mail]
Email Address
336-844-4088
Telephone
336-609-7726
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.
Terry Bumgarner Member
Type or print namee, Title or Authority
Sianatu
Date
1
I, dj it ,(,(t�_y(,, a Notary Public of the County of 11,K n
State of North Carolina, hereby certify that 'TtrrLq Nimurw­ appeared personally
before me this day and being duly sworn acknowled& ifiat thiPabove form was executed by him.
Witness my hand and notarial seal, this _&tday of Vry
20 2f
NNJEFER EDWARDS N
49—
NoGuM Public
North Carolina My commission expires
Wilkes County