NCC221767_FRO Submitted_20220518

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 address or phone
number is unavailable, place N/A in the blank.)
Part A.
1. Project Name Drexel 1 Site
2. Location of land -disturbing activity: County Burke City or Township Drexel
Highwav/Street 101 Main Street Latltude(decimal degrees) 35.76 Longitude(decimal degrees) -81.60
3. Approximate date land -disturbing activity will commence: March 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): Commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 5.0
6. Amount of fee enclosed: $ 500 . The application fee of $100.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: 8.10-acre application fee is $900).
Checks should be addressed to NCDEQ.
7. Has an erosion and sediment control plan been filed? Yes ❑ Enclosed ❑x No ❑
8. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Brian Kvam E-mail Address [e-mail]
Phone: Office # 803 929-6071 Mobile # [phone]
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Town of Drexel 828 430-1794 NIA
Name Phone: Office # Mobile #
PO Box 188 202 Church Street
Current Mailing Address Current Street Address
Drexel, NC 28619 Drexel, NC 28619
City State Zip City State Zip
10. Deed Book No. 2291 Page No. 536 Provide a copy of the most current deed.

1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive list
of all responsible parties on accompanied page.) If the company is a sole proprietorship or if the landowner(s) is
an individual(s), the name(s) of the owner(s) may be listed as the financially responsible party(ies).
Town of Drexel
Company Name
PO Box 188
Current Mailing Address
Drexel, NC 28619
City State Zip
Phone: Office # 828 430-1794
[e-mail]
E-mail Address
202 Church Street
Current Street Address
Drexel, NC 28619
City State Zip
Mobile # NIA
Note: If the Financially Responsible Party is not the owner of the land to be disturbed, include with this form
the landowner's signed and dated written consent for the applicant to submit a draft erosion and sedimentation
control plan and to conduct the anticipated land disturbing activity.
2. (a) If the Financially Responsible Party is a domestic company registered on the NC Secretary of State
business registry, give name and street address of the Registered Agent:
N/A
Name of Registered Agent
N/A
Current Mailing Address
N/A
City
State
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City
Phone: Office # N/A Mobile # N/A
State Zip
N/A
Name of Individual to Contact (if Registered Agent is a company)
(b) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina agent who is registered on the NC Secretary of State business registry:
N/A N/A
Name of Registered Agent E-mail Address
N/A N/A
Current Mailing Address Current Street Address
N/A NIA
City State Zip City State Zip
Phone: Office # N/A Mobile # N/A
N/A
Name of Individual to Contact (if Registered Agent is a company)

(c) If the Financially Responsible Party is engaging in business under an assumed name, give name under
which the company is Doing Business As. If the Financially Responsible Party is an individual, General
Partnership, or other company not registered and doing business under an assumed name, attach a copy
of the Certificate of Assumed Name.
N/A
Company DBA Name
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(s)
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 Party). I agree to provide
corrected information should there be any change in the information provided herein.
Sherri Bradshaw
Type or print name
�lblack,
Signat xe
Town Manager
Title or Authority
4-oyzz,
Date
1, ch G/S d'al `. - Ca rS WC(/ , a Notary Public of the County of z3 y rILe-
State of North Carolina, hereby certify that rSh err { 8, B r`gc(..s hit tou appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him/her.
Witness my hand and notarial seal, this
"N L� Cq,�s
= U NARY r =
PUBLIC v
h
�y fi day of April , 20 2 2.
Notary G/
My commission expires�'

Continued from Items 9 & 10 in Part A of the Financial Responsibility/Ownership Form for multiple
owners. Attach copies of this page as needed to list all landowners.
Landowner 2 of Record:
N/A N/A NIA
Name
N/A
Current Mailing Address
N/A
City State
Deed Book No. N/A
Landowner 3 of Record:
N/A
Name
N/A
Current Mailing Address
N/A
City State
Deed Book No. N/A
Landowner 4 of Record:
N/A
Name
N/A
Current Mailing Address
N/A
Phone: Office # Mobile #
N/A
Current Street Address
N/A
Zip City
Page No. N/A
N/A
State Zip
Provide a copy of the most current deed.
Phone: Office #
N/A
Current Street Address
N/A
Zip City
Page No. N/A
N/A
N/A
Mobile #
State Zip
Provide a copy of the most current deed.
Phone: Office #
N/A
Current Street Address
N/A
City State Zip City
Deed Book No. N/A Page No. N/A
Landowner 5 of Record:
N/A N/A
N/A
Mobile #
State Zip
Provide a copy of the most current deed.
Name Phone: Office #
N/A NIA
Current Mailing Address Current Street Address
N/A N/A
City State Zip City
Deed Book No. N/A Page No. N/A
N/A
Mobile #
State Zip
Provide a copy of the most current deed.

Continued from Item 1 in Part 8 of the Financial Responsibility/Ownership Form for multiple parties.
Attach copies of this page as needed to list all financially responsible parties.
N/A N/A
Company 2 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office # N/A
N/A
Company 3 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office # N/A
N/A
Company 4 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office # N/A
N/A
Company 5 Name
N/A
Current Mailing Address
N/A
City State
Phone: Office # N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City
Mobile # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City
Mobile # N/A
N/A
E-mail Address
N/A
Current Street Address
N/A
Zip City
Mobile # N/A
NIA
E-mail Address
N/A
Current Street Address
N/A
Zip City
Mobile # N/A
State Zip
State Zip
State
Zip
State Zip