NCC217046_FRO Submitted_20211220

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 Adventure Village Erosion Control
2. Location of land -disturbing activity: County Transylvania City or Township Cathey's Creek
Highway/Street Israel Road Latitude 35.165468 Longitude 82.815168
3. Approximate date land -disturbing activity will commence: 11/15/2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.91 AC
6. Amount of fee enclosed: $ 455.00 . 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 Tanner Dale Owen E-mail Address thevillage(i#omporium.net
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Transylvania Evergreen, Inc.
Name
15 Adventure Ridge Road
Current Mailing Address
828-862-5411
Telephone Fax Number
15 Adventure Ridge Road
Current Street Address
Brevard NC 28712 Brevard
City
10. Deed Book No.
Part B.
State Zip City
882 Page No. 578
NC 28712
State
Provide a copy of the most current deed.
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.
Transylvania Evergreen, Inc. thevillagekcomporium.net
Name E-mail Address
15 Adventure Ridge Road
Current Mailing Address
15 Adventure Ridge Road
Current Street Address
Brevard NC 28712 Brevard
City State Zip City
NC
State
28712
Zip

Telephone [phone] Fax Num
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:
Current Mailing Address
Telephone
E-mail Address
Current Street Address
State Zip city State Zip
Fax Number
(b) K the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach acopy qfthe Certificate ufAssumed Name. |fthe Financially Responsible Party
is a Corporation, give name and street address of the Registered Agent:
Name oRegistered Agent
Current Mailing Address
Telephone
E-mail Address
Current Street Address
State Zip city State Zip
Fax Number
The above information iotrue and correct tothe best ofrny knowledge and belief and was
provided
me � under oath (This form must be Signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or�not mn individua|, by an offiner, diren[or, partner, or registered agent with
—e authority to execute instruments for the Financially Responsible Person). | agree to provide
corrected information
[nneUVnshould there be any change inthe information provided herein.
01
Type or print name Title or Authority
Signature
--�� Date
[ aNotary Public ofthe County of
State ofNorth Carolina, henabvce�fvthat appeared
pemone||ybefore me this day
'and being duly sworn acknowledged that the above form was executed
by him.
Witness myhand and notarial seal, this -44~ myof 20
ary
Seil �ILZ Nhcommission expi«_