NCC222283_FRO Submitted_20220706

FINANCIAL RESPONSIBILITYIOWNERSHIP 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 NIA in the blank.)
Part A.
1. Project Name 135 Charlotte St
2. Location of land -disturbing activity: Count Buncombe Asheville
Y City or Township
Highway/Street Charlotte St Latit35.604 82.546
ude{decimal degrees) L.ongltude[decimal degrees]
3. Approximate date land -disturbing activity will commence: June 01, 2022
4. Purpose of development (residential, commercial, industrial, institutional, etc.): residential/commercial
5. Total acreage disturbed or uncovered (including off -site borrow and waste areas): 1.5 aC
6. Amount of fee enclosed: $ 200.00 . 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 ❑ No ❑
S. Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Misty Teague E-mail Address [e-mail]
Phone: Office # 336-731-4396 Mobile # [phone]
Landowner(s) of Record (attach accompanied page to list additional owners):
RCG-Killian Chestnut Residential Properties, LLC 828-676-3025
Name
223 E Chestnut St
Current Mailing Address
Asheville, NC 28801
U lty State
10. Deed Book No. 5828
NIA
Phone: Office # Mobile #
223 E Chestnut St
Current Street Address
Asheville, NC 28801
City State Zip
Page No. 1004 Provide a copy of the most current deed.
Zip

Part B.
1. Company(ies) who are financially responsible for the land -disturbing activity (Provide a comprehensive fist
of all responsible parties on accompanied page.) if the company is a sole proprietorship or if the landowner(s) is
an individual(s), the names) of the owners) may be listed as the financially responsible party(ies).
RCG-Killian Chestnut Residential Properties, LLC
Company Name
223 E Chestnut St
Current Mailing Address
Asheville, NC 28801
Laity State Zip
Phone: Office # 828-676-3025
E-mail Address
223 E Chestnut St
Current Street Address
Asheville, NC 28801
City State
Mobile # N/A
UTE
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 forthe 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:
Krystal Holder
Name of Registered Agent
223 East Chestnut St, Suite 2
Uurrent Mailing Address
Asheville, NC 28801
City
State Zip
E-mail Address
223 East Chestnut St, Suite 2
Current Street Address
Asheville, NC 28801
City State Zip
Phone; office # [phone] NIA
Mobile #
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;
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Phone: Office # Mobile #
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.
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 individuals}
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.
Krystal Holder
Type or print name
Signature
Office Manager
Title or -Authority
Date
I' a Notary Public of the County of
State of orth Carolina, hereby certify that appeared personally
before me this day and being duly sworn ackn edged that the above form was executed by himlher.
Witness my hand and notarial seal, this L5 day of2p_Z?
a Notary Public Notary
Transylvania
County My commission expires - 0
MY Cimm, Exp,
S. -P. ! 2-44-2024
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