NCC217125_FRO Submitted_20220104

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. FRC DCSB
1. Project Name
2. Location of land -disturbing activity: County Rutherford City or Township Forest City
Highway/Street 284 Social Circle Latitude N 35.315833 Longitude W 81.821944
3. Approximate date land -disturbing activity will commence: October 2021
4. Purpose of development (residential, commercial, industrial, institutional, etc.): industrial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 6.94 acres
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 X No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Christine Brown E-mail Address [e-mail]
Telephone [phone] cell # [phone] Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
ANDALE, LLC [phone]
Name Telephone Fax Number
1601 Willow Road same
Current Mailing Address Current Street Address
Menlo Park CA 94025
City State Zip City State Zip
10. Deed Book No. 2037, 1013 Page No. 2246,807 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.
ANDALE, LLC Privacy Redaction
Name
1601 Willow Road
Current Mailing Address
Menlo Park, CA 94025
City
E-mail Address
same
Current Street Address
State Zip City
State
0
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:
N/A
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:
Corporation Service Company
Name of Registered Agent E-mail Address
327 Hillsborough St.
Current Mailing Address Current Street Address
Raleigh NC 27603
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.
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Signature
Title or Authority
Date
01 S CVO f �gv�,Z__ , a Notary Public of the County of v, 5
State of , hereby certify that 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 Iday of 0c,�0 iE✓ , 20 2 f
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