NCC217095_FRO Submitted_20220113

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 SWAIN-2022-001, NPS Great Smoky Mountains National Park, (GRSM 17(1)).
2. Location of land -disturbing activity: County _SWAIN City or Township --Cherokee Highway/
Street_Clingmans Dome Access Road_ Latitude 35 36' 38.9844" N Longitude -83 25' 40.4292" W
3. Approximate date land -disturbing activity will commence: —July 2022_
4. Purpose of development (residential, commercial, industrial, institutional, etc.): —National Park Service_
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas):_1.34 acres_
6. Amount of fee enclosed: $_0 (Total of $133.25 has been sent via check). The application fee of
$65.00 per acre (rounded up to the next acre) is assessed without a ceiling amount.
7. Has an erosion and sediment control plan been filed? Yes Yes, Letter of Approval with Modifications
was issued August 6, 2021_ No Enclosed
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name —Mr. Kevin Rose E-mail [e-mail]
Telephone [phone] Cell # Fax #
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Name Mike Tomkosky Telephone: [phone]
Current Mailing Address: National Park
Service, Great Smoky Mountains National
Park
City Gatlinburg State TN Zip 37738
10. Deed Book No. Page No. Provide a copy of the most current
deed.
Part B.
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.
Name:_FederalHighway Administration,
Eastern Federal Lands
Current Address: 22001 Loudoun Co.
Parkway, Building E-2, Suite 200
City Ashburn, State VA Zip 20147
E-mail Address: [e-mail]

Telephone_(571) 434-1541_
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:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone 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 attomey-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. l
Type or grin e: K ui se Title or Authority:
2 /'/�
S' nature Date
I, Z5!na g Oe,ri , a Notary Public of the County of Lcudid in
V �Y q�nZ a►
State of North, aFe10raa, hereby certify that K C�V\\ v, S Cn FE appeared
personally before me this day and being duly swom acknowledged that the above form was executed
by him.
Witness my hand and notarial seal, this
SHADA ALDOORI
NOTARY PUBLIC
COMMONWEALTH OF VIRGINIA
MY COMMISSION EXPIRES FEB. 28, 2022
Seal._ COMMISSION # 7780878
to%
day of , 20 2_1
Notary
My commission expires -F;6 .1 C 91 J20,27—